Anesthesia & Analgesia

 

November 2006

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

心脏手术中大剂量肽酶的使用:如此大剂量足够吗?8281例心脏手术病人使用肽酶后的分析

宋翠侠 陈杰

High-Dose Aprotinin in Cardiac Surgery: Is High-Dose High Enough?: An Analysis of 8281 Cardiac Surgical Patients Treated with Aprotinin

Wulf Dietrich, Raimund Busley, and Monika Kriner

Anesth Analg 2006 103: 1074-1081.

冠脉旁路移植手术中使用足量酞酶:围手术期药物治疗与患者预后分析

金琳 译,薛张纲 审校

Full-Dose Aprotinin Use in Coronary Artery Bypass Graft Surgery: An Analysis of Perioperative Pharmacotherapy and Patient Outcomes

David Royston, Jerrold H. Levy, Jane Fitch, Wulf Dietrich, Simon C. Body, John M. Murkin, Bruce D. Spiess, and Andrea Nadel

Anesth Analg 2006 103: 1082-1088.

使用全氟化碳减小大鼠体外循环中的气泡大小

裘毅敏译,马皓琳 李士通校

Reduction in Air Bubble Size Using Perfluorocarbons During Cardiopulmonary Bypass in the Rat

Kenji Yoshitani, Fellery de Lange, Qing Ma, Hilary P. Grocott, and G. Burkhard Mackensen

Anesth Analg 2006 103: 1089-1093

左西孟旦对人乳内脉的血管扩张作用

齐波 陈杰

The Vasodilatory Effects of Levosimendan on the Human Internal Mammary Artery

Félix R. Montes, Darío Echeverri, Lorena Buitrago, Isabel Ramírez, Juan C. Giraldo, Javier D. Maldonado, and Juan P. Umaña

Anesth Analg 2006 103: 1094-1098.

择期行心脏外科手术的ASA III-IV患者术前口服碳水化合物

孙敏莉译 薛张纲校

Preoperative Oral Carbohydrate Administration to ASA III-IV Patients Undergoing Elective Cardiac Surgery

Jan-P. Breuer, Vera von Dossow, Christian von Heymann, Markus Griesbach, Michael von Schickfus, Elise Mackh, Cornelia Hacker, Ulrike Elgeti, Wolfgang Konertz, Klaus-D. Wernecke, and Claudia D. Spies

Anesth Analg 2006 103: 1099-1108.

非线性心率变异性分析可预示冠脉搭桥术后的房颤

彭中美 马皓琳 李士通

Nonlinear Heart Rate Variability Analysis May Predict Atrial Fibrillation After Coronary Artery Bypass Grafting (Brief Report)

Dmitri Chamchad, George Djaiani, Hyun Ju Jung, Lev Nakhamchik, Jo Carroll, and Jay C. Horrow

Anesth Analg 2006 103: 1109-1112.

PEDIATRIC ANESTHESIA:

阻塞性睡眠呼吸暂停综合征患儿进行增殖腺扁桃体切除术的围术期并发症

詹琼慧 陈杰

Perioperative Complications of Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome

John C. Sanders, Melinda A. King, Ronald B. Mitchell, and James P. Kelly

Anesth Analg 2006 103: 1115-1121.

臼齿后空间大小对小儿腭面外科手术放置经口气管插管的评估

吴德华译 薛张纲校

An Evaluation of the Retromolar Space for Oral Tracheal Tube Placement for Maxillofacial Surgery in Children

Suman Arora, Vidya Rattan, and Neerja Bhardwaj

Anesth Analg 2006 103: 1122-1125.

用声学反射计测量小儿气道和食道的剖面图

张莹 马皓琳 李士通校

Pediatric Airway and Esophageal Profiles with Acoustic Reflectometry

Gligor Gucev, David T. Raphael, Shlomo Elspas, and Gary Glass

Anesth Analg 2006 103: 1126-1130.

小儿先天性心脏病患者使用肝素的效果以凝血酶制剂浓度的测定

周懿之 陈杰

Clinical Measures of Heparin’s Effect and Thrombin Inhibitor Levels in Pediatric Patients with Congenital Heart Disease

Nina A. Guzzetta, Bruce E. Miller, Kathy Todd, Fania Szlam, Renee H. Moore, Keith K. Brosius, Elizabeth C. Wilson, Anna M. Cohen, and Steven R. Tosone

Anesth Analg 2006 103: 1131-1138.

脉转流手术后的段性室壁运异常提示心肌缺血

王丽珺译 薛张纲校

Segmental Wall-Motion Abnormalities After an Arterial Switch Operation Indicate Ischemia

Kathryn Rouine-Rapp, Kenneth P. Rouillard, Wanda Miller-Hance, Norman H. Silverman, Kathryn K. Collins, Michael K. Cahalan, Alan Bostrom, and Isobel A. Russell

Anesth Analg 2006 103: 1139-1146.

AMBULATORY ANESTHESIA:

吸烟者通过喉罩气道予以地氟醚与七氟醚时的气道反应比较

胡湘译 李士通 马皓琳校

Airway Responses During Desflurane Versus Sevoflurane Administration via a Laryngeal Mask Airway in Smokers

Rachel Eshima McKay, Alan Bostrom, Michel C. Balea, and Warren R. McKay

Anesth Analg 2006 103: 1147-1154.

枢复宁和氟哌利多在预防术后恶心呕吐方面的相互作用

李惟一 陈杰

The Additive Interactions Between Ondansetron and Droperidol for Preventing Postoperative Nausea and Vomiting

Matthew T. V. Chan, Kai C. Choi, Tony Gin, Po Tong Chui, Timothy G. Short, Pong Mo Yuen, Amy H. Y. Poon, Christian C. Apfel, and Tong J. Gan

Anesth Analg 2006 103: 1155-1162.

ANESTHETIC PHARMACOLOGY:

用听觉诱发电位和脑电图评价右旋美托咪啶/雷米太尼和咪达唑仑/雷米太尼对健康人轻到中度镇静的效果

钟静译 薛张纲校

The Effects of Dexmedetomidine/Remifentanil and Midazolam/Remifentanil on Auditory-Evoked Potentials and Electroencephalogram at Light-to-Moderate Sedation Levels in Healthy Subjects

Matthias Haenggi, Heidi Ypparila, Kathrin Hauser, Claudio Caviezel, Ilkka Korhonen, Jukka Takala, and Stephan M. Jakob

Anesth Analg 2006 103: 1163-1169.

对乙酰氨基酚和帕瑞考昔对进行整形手术的老年患者肾能的影响

唐李隽 马皓琳 李士通

The Effects of Paracetamol and Parecoxib on Kidney Function in Elderly Patients Undergoing Orthopedic Surgery

Wolfgang Koppert, Katrin Frötsch, Nilofar Huzurudin, Wolfgang Böswald, Norbert Griessinger, Volker Weisbach, Roland E. Schmieder, and Jürgen Schüttler

Anesth Analg 2006 103: 1170-1176.

MAC多巴胺受体是否部分介导了?

丁震敏 陈杰

Do Dopamine Receptors Mediate Part of MAC?

Yasumasa Tanifuji, Yi Zhang, Mark Liao, Edmond I. Eger, II, Michael J. Laster, and James M. Sonner

Anesth Analg 2006 103: 1177-1181.

TECHNOLOGY, COMPUTING, AND SIMULATION:

机械通气时脉血压和光学体积描记的变化

荻译 薛张纲校

Variations in Arterial Blood Pressure and Photoplethysmography During Mechanical Ventilation

Giuseppe Natalini, Antonio Rosano, Maria E. Franceschetti, Paola Facchetti, and Achille Bernardini

Anesth Analg 2006 103: 1182-1188.

脑监测可以改善异丙酚介导镇静中的眼科手术操作条件吗?

姜旭晖 马皓琳 李士通

Does Cerebral Monitoring Improve Ophthalmic Surgical Operating Conditions During Propofol-Induced Sedation?

Vivian L. B. Oei-Lim, Marcel G. W. Dijkgraaf, Marc D. de Smet, Martin White, and Cor J. Kalkman

Anesth Analg 2006 103: 1189-1195.

围术期监测仪数据不实的问题:一篇临方法的综述

杨卫红 陈杰

The Problem of Artifacts in Patient Monitor Data During Surgery: A Clinical and Methodological Review (Review Article)

George Takla, John H. Petre, D. John Doyle, Mayumi Horibe, and Bala Gopakumaran

Anesth Analg 2006 103: 1196-1204.

CRITICAL CARE AND TRAUMA:

气管内注气通气对气体交换效率的影响

陆文清译 薛张纲校

The Effect of Tracheal Gas Insufflation on Gas Exchange Efficiency

Michael R. Pinsky, Edgar Delgado, and Bernard Hete

Anesth Analg 2006 103: 1213-1218.

始发型和迟发型急性呼吸衰竭:与其发展预后相关的因素

黄佳佳 译,马皓琳 李士通

Initial and Delayed Onset of Acute Respiratory Failure: Factors Associated with Development and Outcome

Suzana M. Lobo, Francisco R. M. Lobo, Flavio Lopes-Ferreira, Daliana Peres Bota, Christian Melot, and Jean-Louis Vincent

Anesth Analg 2006 103: 1219-1223.

NEUROSURGICAL ANESTHESIA:

右旋美托咪啶用于震颤性麻痹病人深部脑刺激物植入术的临经验

宋金超 陈杰

Clinical Experience with Dexmedetomidine for Implantation of Deep Brain Stimulators in Parkinson's Disease

Irene Rozet, Saipin Muangman, Monica S. Vavilala, Lorri A. Lee, Michael J. Souter, Karen J. Domino, Jefferson C. Slimp, Robert Goodkin, and Arthur M. Lam

Anesth Analg 2006 103: 1224-1228.

CT估测非挫伤脑区比重在外伤性脑损伤中作为严重程度的标志

徐丽颖译 薛张纲校

Computed Tomography-Estimated Specific Gravity of Noncontused Brain Areas as a Marker of Severity in Human Traumatic Brain Injury

Vincent Degos, Thomas Lescot, Abderrezak Zouaoui, Harold Hermann, Françoise Préteux, Pierre Coriat, and Louis Puybasset

Anesth Analg 2006 103: 1229-1236.

神经外科手术中以雷米太尼为基础的麻醉后头皮神经阻滞与吗啡用于过渡性镇痛的对比研究

黄丽娜 马皓琳 李士通

A Comparison Between Scalp Nerve Block and Morphine for Transitional Analgesia After Remifentanil-Based Anesthesia in Neurosurgery

Christian Ayoub, François Girard, Daniel Boudreault, Philippe Chouinard, Monique Ruel, and Robert Moumdjian

Anesth Analg 2006 103: 1237-1240.

OBSTETRIC ANESTHESIA:

先兆子痫病人行麻对QT间期的影响

郑丽 陈杰

The Effects of Spinal Anesthesia on QT Interval in Preeclamptic Patients

Selda Sen, Galip Ozmert, Hakan Turan, Eray Caliskan, Alper Onbasili, and Duran Kaya

Anesth Analg 2006 103: 1250-1255

GENERAL ARTICLES:

头颈部过伸可增Mallampati气道评估的特异性和预测价值

王慧琳译 薛张纲校

Craniocervical Extension Improves the Specificity and Predictive Value of the Mallampati Airway Evaluation

George A. Mashour and Warren S. Sandberg

Anesth Analg 2006 103: 1256-1259.

20°头高位能减少甲腺手术后恶心呕吐的发生率和严重程度

王慧琳译 薛张纲校

The Twenty-Degree Reverse-Trendelenburg Position Decreases the Incidence and Severity of Postoperative Nausea and Vomiting After Thyroid Surgery

Kiyo Tominaga and Toshiyuki Nakahara

Anesth Analg 2006 103: 1260-1263.

喉罩通气道和探条插管失败:Combitube是用于住院病人急症气道处理的第二个解救设备

邱郁薇 马皓琳 李士通

Laryngeal Mask Airway and Bougie Intubation Failures: The Combitube as a Secondary Rescue Device for In-Hospital Emergency Airway Management (Brief Report)

Thomas C. Mort

Anesth Analg 2006 103: 1264-1266.

ANALGESIA:

塞来昔布(Celecoxib),普瑞巴林(Pregabalin)其联合使用在柱融合手术中的镇痛效果

周密 陈杰

The Analgesic Efficacy of Celecoxib, Pregabalin, and Their Combination for Spinal Fusion Surgery

Scott S. Reuben, Asokumar Buvanendran, Jeffrey S. Kroin, and Karthik Raghunathan

Anesth Analg 2006 103: 1271-1277.

经斜角肌间沟臂丛神经阻滞行肩关镜手术病人术前给予单次剂量巴喷丁(800mg)不能增术后镇痛效果

路译 薛张纲校

A Single Preoperative Dose of Gabapentin (800 Milligrams) Does Not Augment Postoperative Analgesia in Patients Given Interscalene Brachial Plexus Blocks for Arthroscopic Shoulder Surgery

Frédéric Adam, Christophe Ménigaux, Daniel I. Sessler, and Marcel Chauvin
Anesth Analg 2006 103: 1278-1282.

实验性热疼痛用于检测人娠产生的止痛

张曦 译,马皓琳 李士通

Experimental Heat Pain for Detecting Pregnancy-Induced Analgesia in Humans

Brendan Carvalho, Martin S. Angst, Andrea J. Fuller, Eric Lin, Anbu D. Mathusamy, and Edward T. Riley

Anesth Analg 2006 103: 1283-1287.

妇科手术后的疼痛模式:鞘内注射和全身使用吗啡的不同效应

王震虹 陈杰

A Pain Model After Gynecologic Surgery: The Effect of Intrathecal and Systemic Morphine
Chuanyao Tong, Dawn Conklin, and James C. Eisenach

Anesth Analg 2006 103: 1288-1293.

已有外周感觉运神经疾病或糖尿病性多发性神经病的患者轴索麻醉或镇痛后神经系统并发症

周雅春 马皓琳 李士通

Neurologic Complications After Neuraxial Anesthesia or Analgesia in Patients with Preexisting Peripheral Sensorimotor Neuropathy or Diabetic Polyneuropathy

James R. Hebl, Sandra L. Kopp, Darrell R. Schroeder, and Terese T. Horlocker

Anesth Analg 2006 103: 1294-1299.

胫后神经阻滞中一个近端阻滞点的评估和神经刺激导向装置针的使用

顾新宇 陈杰

Evaluation of a Proximal Block Site and the Use of Nerve-Stimulator-Guided Needle Placement for Posterior Tibial Nerve Block

Robert Doty, Jr, Radha Sukhani, Mark C. Kendall, Edward Yaghmour, Antoun Nader, Alina Brodskaia, Tripti C. Kataria, and Robert McCarthy

Anesth Analg 2006 103: 1300-1305.

三维核磁共振影像用于人类腰段脑液容量的测定

韩晓丹译 薛张纲校

Lumbosacral Cerebrospinal Fluid Volume in Humans Using Three-Dimensional Magnetic Resonance Imaging

John T. Sullivan, Sharon Grouper, Matthew T. Walker, Todd B. Parrish, Robert J. McCarthy, and Cynthia A. Wong

Anesth Analg 2006 103: 1306-1310.

柱大手术后镇痛:病人自控硬膜外镇痛与病人自控静脉镇痛的比较

颜涛 译, 马皓琳 李士通

Postoperative Analgesia After Major Spine Surgery: Patient-Controlled Epidural Analgesia Versus Patient-Controlled Intravenous Analgesia

Michael R. Schenk, Michael Putzier, Bjoern Kügler, Stephan Tohtz, Kristina Voigt, Tania Schink, Wolfgang J. Kox, Claudia Spies, and Thomas Volk

Anesth Analg 2006 103: 1311-1317.

比较中胸段和低胸段硬膜外间隙硬膜外压和低于大气压的硬膜外压的发生率的差异

曹瑜 陈杰

A Comparison of Epidural Pressures and Incidence of True Subatmospheric Epidural Pressure Between the Mid-Thoracic and Low-Thoracic Epidural Space

W. Anton Visser, Mathieu J. M. Gielen, Janneke L. P. Giele, and Gert J. Scheffer

Anesth Analg 2006 103: 1318-1321.

局部麻醉药物的心脏毒性:一项麻醉院系关于当代临实践的调查研究

韩晓丹译 薛张纲校

Local Anesthetic-Induced Cardiac Toxicity: A Survey of Contemporary Practice Strategies Among Academic Anesthesiology Departments

William Corcoran, John Butterworth, Robert S. Weller, Jonathan C. Beck, J. C. Gerancher, Timothy T. Houle, and Leanne Groban

Anesth Analg 2006 103: 1322-1326.

 

使用全氟化碳减小大鼠体外循环中的气泡大小

Reduction in Air Bubble Size Using Perfluorocarbons During Cardiopulmonary Bypass in the Rat

Kenji Yoshitani, MD*, Fellery de Lange, MD*{dagger}, Qing Ma, MD*, Hilary P. Grocott, MD, FRCPC*, and G. Burkhard Mackensen, MD*

From the *Department of Anesthesiology, Duke University Medical Center; and {dagger}Division of Perioperative Care and Emergency Medicine, University Medical Center, Utrecht, the Netherlands.

Anesth Analg 2006;103:1089-1093

 

背景:全氟化碳 (PFC) 乳剂是人造的携氧化合物,对气体有很高的溶解性,实验已显示能改善脑气栓。脑气栓与用体外循环(CPB)的心脏手术后的脑部不良反应有关。我们设计本研究的目的是测试PFC乳剂是否能减少CPB回路中气泡的体积。方法:将进行60 min常温非搏性CPB的雄性Sprague-Dawley大鼠随机分为3组。PFC(n = 10)通过膜肺接受60% O2/36% N2/4% CO2进入静脉储液罐的2.7 g/kg (4.5 mL/kg) PFC;对照组(n = 10)接受同样的混合气体4.5 mL/kg的生理盐水。N2O (n = 6)暴露于36% N2O/60% O2/4% CO2中,并接受4.5 mL/kg的生理盐水。CPB10min 35 min400 µL的空气注入CPB回路中的气泡室。20 min后去除气泡作容积分析。结果:与基础值比较,PFC组的气泡体积减小了13% ± 5%N2O 组的气泡体积增大了46% ± 9%,这两组的变化与对照组相比均有显著性差异(P < 0.0001)结论:结果提示给予PFC对减小CPB中出现的气泡体积可能是有用的。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: Perfluorocarbon (PFC) emulsions are artificial oxygen-carrying compounds with a high solubility for gases that have experimentally been shown to ameliorate cerebral air embolism. Cerebral air embolism has been associated with adverse cerebral outcomes after cardiac surgery using cardiopulmonary bypass (CPB). We designed this study to test whether PFC emulsions could reduce the volume of bubbles within the CPB circuit.

METHODS: Male Sprague-Dawley rats undergoing 60 min of normothermic nonpulsatile CPB were randomized to one of the three groups. The PFC group (n = 10) received 60% O2/36% N2/4% CO2 via the membrane oxygenator and 2.7 g/kg (4.5 mL/kg) of PFC into the venous reservoir; the control group (n = 10) received the same gas mixture and 4.5 mL/kg of saline; the N2O group (n = 6) was exposed to 36% N2O/60% O2/4% CO2 and received 4.5 mL/kg of saline. After 10 min and 35 min of CPB, 400 µL of air was injected into a bubble chamber in the CPB circuit. After 20 min, the bubble was removed for volumetric analysis.

RESULTS: Compared with baseline, the bubble decreased 13% ± 5% in size in the PFC group and increased 46% ± 9% in the nitrous oxide group, both of these changes significantly different from the control group (P < 0.0001).

CONCLUSION: The results suggest that PFC administration may be useful in reducing the volume of gaseous bubbles present during CPB.

 

 

非线性心率变异性分析可预示冠脉搭桥术后的房颤

Nonlinear Heart Rate Variability Analysis May Predict Atrial Fibrillation After Coronary Artery Bypass Grafting

Dmitri Chamchad, MD*, George Djaiani, MD{dagger}, Hyun Ju Jung, MD{dagger}, Lev Nakhamchik, MSc{dagger}, Jo Carroll, RN{dagger}, and Jay C. Horrow, MD, MS{ddagger}

From the *Department of Anesthesia, Lankenau Hospital, Wynnewood, Pennsylvania; {dagger}Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada; and {ddagger}Department of Anesthesia, Drexel University College of Medicine, Philadelphia, Pennsylvania.

Anesth Analg 2006;103:1109-1112

 

背景:心率变异性可能预示冠脉搭桥术后的心律失常。方法:对患者连续10分钟心电图记录的脱机处理通过逐步多元对数回归提供了R-R间期的时域、频域、Poincaré,和点相关分析随后与术后房颤的相关性。结果:符合入围标准的88例患者中,13例发生房颤。峰值点关联维数(优比 3.985/单位, P = 0.0096)和年龄(优比 1.144/yr, P = 0.0019) 与房颤有独立的相关性 (c-统计值 = 0.839)结论:进一步的研究应该确定峰值点关联维数能预示体外循环下行冠脉搭桥术后房颤的发生。

(彭中美 马皓琳 李士通 校)

BACKGROUND: Heart rate variability might predict arrhythmias after coronary artery bypass grafting.

METHODS: Off-line processing of 10-min electrocardiogram recordings of consecutive patients provided R–R intervals for time domain, frequency domain, Poincaré, and point correlation analyses and subsequent association with postoperative atrial fibrillation by stepwise multivariate logistic regression.

RESULTS: Of 88 patients who met entry criteria, 13 developed atrial fibrillation. Peak point correlation dimension (odds ratio 3.985/unit, P = 0.0096) and age (odds ratio 1.144/yr, P = 0.0019) were independently associated with atrial fibrillation (c-statistic = 0.839).

CONCLUSIONS: Further study should confirm the ability of peak point correlation dimension to predict atrial fibrillation after coronary artery surgery with cardiopulmonary bypass.

 

 

用声学反射计测量小儿气道和食道的剖面图

Pediatric Airway and Esophageal Profiles with Acoustic Reflectometry

Gligor Gucev, MD*, David T. Raphael, MD, PhD*, Shlomo Elspas, MD*, and Gary Glass{dagger}

From the *Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California; and {dagger}E. Benson Hood Laboratories, Pembroke, Massachusetts.

Anesth Analg 2006;103:1126-1130

 

用声学反射计的激素检查可以以面积-深度剖面的形式,评估一个空腔的三维特征。我们进行了一个初步研究在212-12岁儿童中得到与放置和定位呼吸管(气管导管,ETT,内径4.5–6 mm)有关的声学反射计(AR)成像。与以往在成人中记录的相同,在儿童也得到了特征性AR剖面可用于气道和食道插管。两种剖面都显示在整个气管内导管长度的面积是恒定的,在之后的远端,气道面积有快速增,但食道面积降低到近乎零水平。与气管剖面相比,支气管插管显示隆突远端气道面积减少。随气管内插管深,气管内导管和支气管壁将发生紧密相贴,使深度的气道面积减少。我们讨论了儿童和新生儿中气管内导管紧贴壁的发生,以其可能的AR发现和治疗。

(张莹 马皓琳 李士通校)

Acoustic reflectometry is a technique by which the dimensions of a cavity can be estimated in the form of an area–distance profile. We conducted a pilot study to obtain the acoustic reflectometry (AR) images associated with breathing tube (endotracheal tube, ETT) placement (inner diameter 4.5–6 mm) and positioning in 21 (n = 21) children, aged 2–12 yr. Characteristic AR profiles, as previously noted in adults, were obtained for tracheal and esophageal intubations in children. Both types of profiles showed constant area throughout the ETT length, followed distally by either a rapid area increase (tracheal) or an area decrease to a near zero value (esophageal). Relative to a tracheal profile, a bronchial intubation exhibits a decrease in area distal to the carina position. With deeper ETT insertion, abutment of the ETT against the bronchial wall can occur, with a possible profound area decrease. The occurrence of ETT abutment in children and neonates, and its possible AR detection and treatment, is discussed.

 

 

吸烟者通过喉罩气道予以地氟醚与七氟醚时的气道反应比较

Airway Responses During Desflurane Versus Sevoflurane Administration via a Laryngeal Mask Airway in Smokers

Rachel Eshima McKay, MD*, Alan Bostrom, PhD{dagger}, Michel C. Balea, MS*, and Warren R. McKay, MD*

From the *Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; and {dagger}Department of Epidemiology and Biostatistics; University of California San Francisco, San Francisco, California.

Anesth Analg 2006;103:1147-1154

 

与不吸烟者比较,吸烟者在麻醉中发生呼吸道并发症的概率更大。不知道一个吸入性麻醉药的相对刺激性是否会增吸烟者的这些呼吸道并发症的发生率。在本研究中,我们测试了是否使用更刺激的麻醉剂(地氟醚)会导致吸烟者咳嗽、憋气、喉痉挛或者氧饱和度下降的发生率更高。我们随机分配了110名吸烟者应用地氟醚(n=55)或者七氟醚(n=55)麻醉,经由喉罩通气道给予。5个接受地氟醚的病人(9%)9个接受七氟醚的病人(16%)有咳嗽(P = 0.39)。绝大多数的咳嗽发生在诱导过程中(33%)或在气道操作与低浓度麻醉中出现(56%)。憋气、喉痉挛或者氧饱和度下降的发生率在接受地氟醚与七氟醚对比的患者之间是相近的。回顾性的比较这一组110位吸烟者与以前接受同样的麻醉方法的一组包括100名非吸烟者和27名吸烟者显示使病人呼吸系统并发症的风险增的是吸烟而不是麻醉药物的选择。

(胡湘译 李士通 马皓琳校)

Cigarette smokers have a greater risk of respiratory complications during anesthesia compared with nonsmokers. It is not known whether the relative pungency of an inhaled anesthetic further contributes to the smokers’ increased rate of such complications. In the present study, we tested whether the use of a more pungent anesthetic (desflurane) would result in a higher rate of coughing, breath holding, laryngospasm, or desaturation among patients who smoke. We randomly assigned 110 smokers to anesthesia with desflurane (n = 55) or sevoflurane (n = 55), administered via a laryngeal mask airway. Five patients (9%) receiving desflurane and nine patients (16%) receiving sevoflurane coughed (P = 0.39). Most coughing occurred during induction (33%) or emergence (56%), in the setting of airway manipulation and low anesthetic concentration. The rate of breath holding, laryngospasm, and desaturation was similar between those receiving desflurane versus sevoflurane. A retrospective comparison of this cohort of 110 smokers to a previous group consisting of 100 nonsmokers and 27 smokers receiving an identical anesthetic regimen indicates that cigarette smoking, but not choice of anesthetic, places patients at increased risk of respiratory complications.

 

 

对乙酰氨基酚和帕瑞考昔对进行整形手术的老年患者肾能的影响

The Effects of Paracetamol and Parecoxib on Kidney Function in Elderly Patients Undergoing Orthopedic Surgery

Wolfgang Koppert, MD, Priv.-Doz.*, Katrin Frötsch, MD*, Nilofar Huzurudin, MD*, Wolfgang Böswald, MD*, Norbert Griessinger, MD*, Volker Weisbach, MD, Priv.-Doz.{dagger}, Roland E. Schmieder, MD, Professor{ddagger}, and Jürgen Schüttler, MD, Professor*

From the Departments of *Anesthesiology, {dagger}Transfusion Medicine and Haemostaseology, {ddagger}Nephrology and Hypertension, University Hospital Erlangen, D-91054 Erlangen, Germany.

Anesth Analg 2006;103:1170-1176

 

传统非甾体类炎药对肾能的一般不良作用通常包括肾血流量、肾小球滤过率和钠钾排泄的减少,主要通过制肾环氧合酶起作用。我们设计了本研究以确定对静脉注射乙酰氨基酚或帕瑞考昔对进行整形手术的老年患者肾能的影响。75例行髋关置换或股骨干手术的患者(76 ± 8 ,均数 ±标准差)完成了该项随机化的安慰剂对照研究。患者进入麻醉后监室后,就给予研究药物的初始剂量:对乙酰氨基酚1000 mg 静脉注射(n = 25),帕瑞考昔 40 mg 静脉注射 (n = 25),或盐水静脉注射 (n = 25);追量在之后的三天内给予。阿片类作为补救药物供给。在术前术后采集血、尿样本,并测定肾能标记物。在给予帕瑞考昔初始剂量后的前两小时内,肌酐清除率略微减少(125 ± 83 86 ± 45 mL/min, P < 0.05),而在安慰剂组和对乙酰氨基酚组中观察到肌酐清除率无明显减少。在所有的处理之后,钠、钾、尿白蛋白、α

 
-1-微球蛋白的排泄短暂升高(组间差异无显著性)。总之,整形手术后所有患者的球管能皆有短暂受累,然而,不同处理组间的差异很小,且无临相关性。进一步的研究应致于用此类药物更长期治疗的肾脏不良反应,尤其是那些有肾能减退或合并症的患者。

(唐李隽 马皓琳 李士通 校)

The common adverse effects of traditional nonsteroidal antiinflammatory drugs on renal function include reductions in renal blood flow, glomerular filtration rate, and sodium and potassium excretion, mainly via inhibition of renal cyclooxygenase. We designed the present study to determine the effects of IV paracetamol or parecoxib on renal function in elderly patients undergoing orthopedic surgery. Seventy-five patients (76 ± 8 yr, mean ± sd) undergoing hip replacement or surgery of the femoral shaft completed this randomized and placebo-controlled study. After their arrival in the postanesthesia care unit, patients received an initial dose of the study medication, paracetamol 1000 mg IV (n = 25), parecoxib 40 mg IV (n = 25), or saline IV (n = 25); subsequent doses were administered for the next 3 days. Opioids were provided as rescue medication. Blood and urine samples were collected before and after surgery, and markers of renal function were determined. During the first 2 h after the initial dose of parecoxib, creatinine clearance was slightly diminished (125 ± 83 to 86 ± 45 mL/min, P < 0.05), whereas no significant decrease of creatinine clearance was observed in the placebo and paracetamol groups. After all treatments, sodium and potassium excretion as well as urine albumin and {alpha}-1-microglobulin were transiently increased (group differences: not signicifant). In conclusion, glomerular and tubular functions were transiently affected in all patients after orthopedic surgery; however, the differences between the treatment groups were small and not clinically relevant. Further studies are warranted to determine adverse renal effects of longer-lasting therapy with these drugs, especially in patients with renal impairment or concomitant diseases.

 

 

脑监测可以改善异丙酚介导镇静中的眼科手术操作条件吗?

Does Cerebral Monitoring Improve Ophthalmic Surgical Operating Conditions During Propofol-Induced Sedation?

Vivian L. B. Oei-Lim, MD, PhD*, Marcel G. W. Dijkgraaf, PhD{dagger}, Marc D. de Smet, MDCM, PhD{ddagger}, Martin White, MD, PhD*, and Cor J. Kalkman, MD, PhD

From the Departments of *Anesthesiology, {dagger}Clinical Epidemiology & Biostatistics, {ddagger}Ophthalmology, Academic Medical Center, University of Amsterdam, Amsterdam; and §Department of Anesthesiology, University Medical Center, University of Utrecht, Utrecht, Netherlands.

Anesth Analg 2006;103:1189-1195

 

眼科手术中病人从深度镇静条件中突然发生体将对眼睛造成损害。有道指出双谱指数(BIS)和中潜伏期听觉诱发电位(腋生的AEP指数,AAI)是镇静水平和意识消失的准确指标。我们在镇静过程中评估这些监测指标,特别强调防止过度镇静。100例排定行择期眼科手术的病人用靶控输注异丙酚进行镇静,并随机地分入BIS指导组、AAI指导组、BIS/AAI指导组或临指导组(每组n =25)。超过70岁的病人的异丙酚初始靶浓度是0.5 µg · mL–1,其余所有病人1.0 µg · mL–1。每3分钟分别增靶浓度0.1 or 0.2 µg · mL–1,直到病人的BIS值达到75(70—90)AAI达到40(35—60)。不知分组的眼科医生在术后评价处理质量。有四位病人因为过多的头而改为全身麻醉。BIS值在7%的手术时间中超出了范围,AAI值在58%的时间超出了范围。四组病人之间的处理质量没有显著性差别。我们得出结论,用BISAAI监测指导的异丙酚镇静和单纯的临观测指导的镇静相比,并不改善眼科手术的操作条件。

(姜旭晖 马皓琳 李士通 校)

Sudden movements from over-sedation during ophthalmic surgery can be detrimental to the eye. Bispectral index (BIS) and middle-latency auditory-evoked potentials (Alaris AEP index, AAI) were reported to be accurate indicators for the level of sedation and loss of consciousness. We assessed these monitors during sedation with special emphasis on preventing over-sedation. One-hundred patients scheduled for elective eye surgery were sedated with target-controlled propofol infusion and randomly allocated to BIS-guided, AAI-guided, BIS/AAI-guided, or clinically guided groups (n = 25 each). The initial target concentration was 0.5 µg · mL–1 in patients >70 yr and 1.0 µg · mL–1 in all other patients. The concentration was increased every 3 min by 0.1 or 0.2 µg · mL–1, respectively until the patient had reached a BIS value of 75 (range 70–90) or an AAI of 40 (range 35–60). The surgeon who was blinded to group allocation assessed treatment quality after the procedure. Sedation was converted into general anesthesia in four patients because of excessive head movements. BIS was out of range 7% of the time vs 58% for AAI. No significant differences in treatment quality were observed among the four groups. We conclude that propofol sedation, guided by BIS or AAI monitoring, did not enhance ophthalmic surgical operating conditions over sedation guided by clinical observation only.

 

 

始发型和迟发型急性呼吸衰竭:与其发展预后相关的因素

Initial and Delayed Onset of Acute Respiratory Failure: Factors Associated with Development and Outcome

Suzana M. Lobo, MD, Francisco R. M. Lobo, MD, Flavio Lopes-Ferreira, MD, Daliana Peres Bota, MD, Christian Melot, MD, PhD, and Jean-Louis Vincent, MD, PhD

From the Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium.

Anesth Analg 2006;103:1219-1223

 

在对31内外科重症监室(ICU)中收入的1038例成年患者的前瞻性观察研究中发现,入住ICU的时间超过48小时的313例患者中有182例(58%)发生急性呼吸衰竭(ARF,定义为Pao2/Fio2 200 mm Hg并且需要呼吸支持)。其中,133例(42%)患者发生始发型ARF(入住ICU48小时内发生);49例(16%)患者发生迟发型ARF(入住ICU48小时以后发生)。在收入ICU时,心血管序贯性器官能衰竭评估 SOFA)分数在始发型ARF 患者中比 迟发型ARF患者高(1.1 ± 1.5 vs 0.6 ± 1.2, P < 0.05) 另外,高血浆C-反应蛋白浓度(OR 1.08, 95% CI 1.04–1.12, P = 0.0001)和高SOFA评分(OR 1.20, 95% CI 1.08–1.33, P = 0.0007)是始发型ARF的独立相关因素,低Glasgow 昏迷等级(GCS)评分(OR 1.13, 95% CI 1.04–1.21, P = 0.0018)与迟发型ARF相关。在始发型ARF中收入ICU时的高 SOFA 评分(OR 1.24, 95% CI 1.12–1.38, P = 0.0001)和低 GCS 评分 (OR 0.89, 95% CI 0.83–0.96, P = 0.0013)以迟发型ARF48 h 时的低 GCS 评分(OR 0.67, 95% CI 0.54–0.84, P = 0.0011)是独立的死亡相关因素。两者的死亡率是相似的。

(黄佳佳 译,马皓琳 李士通 校)

In a prospective observational study of 1038 adult admissions to a 31-bed medical/surgical intensive care unit (ICU), acute respiratory failure (ARF, defined as a Pao2/Fio2 ratio 200 mm Hg and the need for respiratory support) occurred in 182 (58%) of the 313 admissions with an ICU stay of more than 48 h. Initial ARF (onset within 48 h of ICU admission) occurred in 133 (42%) patients, and delayed onset ARF (onset >48 h after ICU admission) in 49 (16%). On admission, the cardiovascular sequential organ failure assessment (SOFA) score was higher in initial than in delayed onset ARF (1.1 ± 1.5 vs 0.6 ± 1.2, P < 0.05). High admission serum C-reactive protein concentrations (OR 1.08, 95% CI 1.04–1.12, P = 0.0001) and SOFA scores (OR 1.20, 95% CI 1.08–1.33, P = 0.0007) were the factors independently associated with initial ARF, and a low Glasgow coma scale (GCS) score (OR 1.13, 95% CI 1.04–1.21, P = 0.0018) was associated with delayed onset ARF. In initial ARF, a high SOFA score (OR 1.24, 95% CI 1.12–1.38, P = 0.0001) and a low GCS score (OR 0.89, 95% CI 0.83–0.96, P = 0.0013) on admission, and in delayed onset ARF, a low GCS score at 48 h (OR 0.67, 95% CI 0.54–0.84, P = 0.0011) were independently associated with death. The mortality rate was similar for initial and delayed onset ARF.

 

 

神经外科手术中以雷米太尼为基础的麻醉后头皮神经阻滞与吗啡用于过渡性镇痛的对比研究

A Comparison Between Scalp Nerve Block and Morphine for Transitional Analgesia After Remifentanil-Based Anesthesia in Neurosurgery

Christian Ayoub, MD, B. Pharm*, François Girard, MD, FRCPC*, Daniel Boudreault, MD, FRCPC*, Philippe Chouinard, MD, FRCPC*, Monique Ruel, RN*, and Robert Moumdjian, MD, FRCS(C){dagger}

From the *Department of Anesthesiology, and {dagger}Neurosurgery division, CHUM, Hôpital Notre-Dame, Montréal, Canada.

Anesth Analg 2006;103:1237-1240

 

我们比较了以雷米太尼为基础的麻醉的神经外科手术后头皮神经阻滞(SNB)与吗啡提供的过渡性镇痛。50例颅骨切开术病人随机分入两组:吗啡组和阻滞组。吗啡组在硬膜关闭后静脉注射0.1 mg · kg–1吗啡,手术结束时用20mL生理盐水行SNB;阻滞组在硬膜关闭后用10mL生理盐水替代吗啡,手术结束时用0.5%布比卡因与2%利多卡因的11混合液行SNB。用10分数字化等级量表评定术后1248121624小时的疼痛程度。镇痛包括皮下注射可待因。数字化等级量表评分的平均值在两组间每一个时间间隔是相似的。除了术后4小时阻滞组的可待因剂量较大外,两组总的可待因剂量也是相似的。可待因首剂量注射前的滞时在两组间也无统计学差异:阻滞组和吗啡组的中位数和范围分别为45 分钟 (20–2880) 30 分钟(10–2880)。两组间术后血流学相似。恶心呕吐的发生率在吗啡组略高,但是意识混乱的发生在两组间没有差异。总之,头皮神经阻滞可以提供与吗啡相似的过渡性镇痛质量,并且两者术后的血流学变化相同。

(黄丽娜 马皓琳 李士通 校)

We compared transitional analgesia provided by scalp nerve block (SNB) or morphine after remifentanil-based anesthesia in neurosurgery. Fifty craniotomy patients were randomly divided into two groups: morphine (morphine 0.1 mg · kg–1 IV after dural closure and an SNB performed with 20 mL of 0.9% saline at the end of surgery) and block (10 mL of 0.9% saline instead of morphine after dural closure and an SNB performed with a 1:1 mixture of bupivacaine 0.5% and lidocaine 2% at the end of surgery). Postoperative pain was assessed at 1, 2, 4, 8, 12, 16, and 24 h using a 10-point numerical rating scale. Analgesia consisted of subcutaneous codeine. Average numerical rating scale scores were similar between the two groups at each time interval. Total codeine dosage was also similar, except at 4 h postoperatively when it was higher in the block group. The delay before administration of the first dose of codeine was not statistically different between groups: 45 min (20–2880) vs 30 min (10–2880), median and range for the block and morphine group, respectively. Postoperative hemodynamics were similar for both groups. The incidence of nausea and vomiting was slightly more frequent in the morphine group, but the occurrence of confusion did not differ between groups. In conclusion, SNB provides a quality of transitional analgesia that is similar to that of morphine with the same postoperative hemodynamic profile.

 

 

喉罩通气道和探条插管失败:Combitube是用于住院病人急症气道处理的第二个解救设备

Laryngeal Mask Airway and Bougie Intubation Failures: The Combitube as a Secondary Rescue Device for In-Hospital Emergency Airway Management

Thomas C. Mort, MD*{dagger}

From the *Department of Anesthesiology, Simulation Center, Hartford Hospital, Hartford and {dagger}Department of Anesthesiology, University of Connecticut School of Medicine, Farmington, Connecticut.

Anesth Analg 2006;103:1264-1266

 

当传统插管方法失败时,备用的救气道设施必须时可行且迅速协临医师控制气道。我回顾了急插管数据库,从而明确哪个导气管设施是用作救初步救设备失败时的后备设备。探条和喉罩通气道均有自身的失败率。在住院情况当探条和喉罩通气道失败时,常用于急未住院病人的Combitube®看来是一种有用的二级救设备。

(邱郁薇 马皓琳 李士通 译)

When conventional intubation methods fail, an accessory rescue airway device must be immediately available and rapidly deployed to assist the clinician in managing the airway. I reviewed an emergency intubation database to determine what airway devices were used as a backup to rescue the primary rescue device failures. The bougie and the laryngeal mask airway each have an intrinsic failure rate. The Combitube®, commonly used in the emergency prehospital setting, appeared to be a useful secondary rescue device in the hospital setting when the bougie and laryngeal mask airway failed.

 

 

实验性热疼痛用于检测人娠产生的止痛

Experimental Heat Pain for Detecting Pregnancy-Induced Analgesia in Humans

Brendan Carvalho, MBBCh, FRCA*, Martin S. Angst, MD*, Andrea J. Fuller, MD{dagger}, Eric Lin, MD{ddagger}, Anbu D. Mathusamy, MD, and Edward T. Riley, MD*

From the *Department of Anesthesia, Stanford University School of Medicine, Stanford, Californi; at Northern Colorado Anesthesia Professional Consultants, Fort Collins, Colorado; {ddagger}University of California San Francisco, San Francisco, California; and Bronx-Lebanon Hospital, Bronx, New York.

Anesth Analg 2006;103:1283-1287

 

物实验提示,增循环中的雌激素和黄体酮活化内啡肽系统产生娠引起的伤害感受效应。人类的研究已提供了不一致的结果,而且常常缺少一个非娠对照组。在这个研究中,我们比较娠妇女和非娠妇女对试验性热和冷疼痛的敏感度。选入19个健康的非娠女性志愿者和20个娠足月妇女。用实验性热导致的疼痛和冷压疼痛模型,检测疼痛的阈值和耐受。分别在分娩前和分娩后1-2天(娠组)或连续几天(非娠组)评估受试者。比较非娠对照组,分娩前和分娩后娠妇女的热疼痛的耐受性较显著增(49.0 ± 1.2 50.0 ± 1.0 49.2 ± 1.250.1 ± 0.7°C;平均数±标准差)。然而,冷压试验导致的疼痛在两个研究组忍受了相似的时间。足月娠导致的止痛效应可以通过实验性热疼痛检测。这种效应持续到产后24-48小时。实验性热疼痛是用于进一步描述人类娠导致止痛现象的一个合适的模式。

(张曦 译,马皓琳 李士通 校)

Animal studies suggest that increased circulating estrogen and progesterone, and activation of the endorphin system cause prenancy-induced antinociceptive effects. Human studies have provided inconsistent results and have often lacked a nonpregnant control group. In this study, we compared sensitivity to experimental heat and cold pain in pregnant and nonpregnant women. Nineteen healthy nonpregnant female volunteers and 20 pregnant women at term were enrolled. Pain threshold and tolerance were examined using experimental heat-induced pain and cold pressor pain models. Subjects were evaluated pre- and 1–2 days post-delivery (pregnant), or on consecutive days (nonpregnant). Heat pain tolerance was significantly increased in the pregnant women during pre and postdelivery when compared with nonpregnant controls (50.0 ± 1.0 vs 49.0 ± 1.2 and 50.1 ± 0.7 vs 49.2 ± 1.2°C; mean ± sd). However, pain induced by the cold pressor test was endured for a similar amount of time by both study groups. Pregnancy-induced analgesic effects at term can be detected in a model of experimental heat pain. These effects persist during the first 24–48 h after delivery. Experimental heat pain is a suitable modality for further characterizing the phenomenon of pregnancy-induced analgesia in humans.

 

 

已有外周感觉运神经疾病或糖尿病性多发性神经病的患者轴索麻醉或镇痛后神经系统并发症

Neurologic Complications After Neuraxial Anesthesia or Analgesia in Patients with Preexisting Peripheral Sensorimotor Neuropathy or Diabetic Polyneuropathy

 

James R. Hebl, MD*, Sandra L. Kopp, MD*, Darrell R. Schroeder, MS{dagger}, and Terese T. Horlocker, MD*

From the *Department of Anesthesiology; and {dagger}Section of Biostatistics, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota.

Anesth Analg 2006;103:1294-1299

 

背景:轴索阻滞后严重神经系统并发症的风险在普通人群中非常罕见。但是原先有神经系统损害的患者在轴索麻醉或镇痛后进一步发生神经损害后遗症的风险性可能增。方法:我们回顾性调查了567名在轴索麻醉或镇痛前患有外周感觉运神经疾病或糖尿病性多发性神经病的患者。收集每个患者的人口统计学信息、神经系统病史、轴索阻滞的适应症类型、并发症和阻滞预后。结果:大部分病人在接受阻滞时具有稳定的慢性神经系统体征或症,只有很少部分病人在接受阻滞前六个月内神经系统症进一步重。轴索阻滞的种类包括:325名患者麻(57%)、214名患者硬膜外麻醉或镇痛(38%)、24名患者连续麻(4%)4名患者腰硬联合麻醉(1%)。在所有患者中,2名患者(0.4%; 95% 可信限 0.1%–1.3%)在手术后出现新的或重的神经能缺失。此2名患者轴索阻滞操作过程中无特事件发生。在这些患者中,轴索阻滞可能促成继发于已受损神经周围直接创伤和局麻药神经毒性的损伤。63名患者中发生了65项(11.5%)与术操作有关的并发症。最常见的并发症是无意中引发的感觉异常(7.6%),其次是有出血证据的损伤性置针(1.6%)和意外穿破硬膜(0.9)。没有发生感染或血液学性并发症。结论:我们发现接受轴索麻醉或镇痛的外周感觉运神经疾病或糖尿病多发神经病患者严重术后神经能障碍的发生率为0.4%95% 可信限0.1%–1.3%)。临医师在开展和实施区域麻醉性监计划时应该意识到这一潜在的高危性亚人群。

(周雅春 马皓琳 李士通 校)

BACKGROUND: The risk of severe neurologic injury after neuraxial blockade is extremely rare among the general population. However, patients with preexisting neural compromise may be at increased risk of further neurologic sequelae after neuraxial anesthesia or analgesia.

METHODS: We retrospectively investigated 567 patients with a preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy who subsequently underwent neuraxial anesthesia or analgesia. Patient demographics, neurologic history, the indication and type of neuraxial blockade, complications, and block outcome were collected for each patient.

RESULTS: The majority of patients had chronically stable neurologic signs or symptoms at the time of block placement, with very few reporting progression of their symptoms within the last 6 mo. The type of neuraxial technique included spinal anesthesia in 325 (57%) patients, epidural anesthesia or analgesia in 214 (38%) patients, continuous spinal anesthesia in 24 (4%) patients, and a combined spinal-epidural technique in four (1%) patients. Overall, two (0.4%; 95% CI 0.1%–1.3%) patients experienced new or progressive postoperative neurologic deficits, in the setting of an uneventful neuraxial technique. In these patients, the neuraxial block may have contributed to the injury secondary to direct trauma or local anesthetic neurotoxicity around an already vulnerable nerve. Sixty-five (11.5%) technical complications occurred in 63 patients. The most common complication was unintentional elicitation of a paresthesia (7.6%), followed by traumatic (evidence of blood) needle placement (1.6%) and unplanned dural puncture (0.9%). There were no infectious or hematologic complications.

CONCLUSIONS: The risk of severe postoperative neurologic dysfunction in patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing neuraxial anesthesia or analgesia was found to be 0.4% (95% CI 0.1%–1.3%). Clinicians should be aware of this potentially high-risk subgroup of patients when developing and implementing a regional anesthetic care plan.

 

 

柱大手术后镇痛:病人自控硬膜外镇痛与病人自控静脉镇痛的比较

Postoperative Analgesia After Major Spine Surgery: Patient-Controlled Epidural Analgesia Versus Patient-Controlled Intravenous Analgesia

Michael R. Schenk, MD*, Michael Putzier, MD{dagger}, Bjoern Kügler*, Stephan Tohtz, MD{dagger}, Kristina Voigt*, Tania Schink{ddagger}, Wolfgang J. Kox, FRCP*, Claudia Spies, MD*, and Thomas Volk, MD*

From the Departments of *Anesthesiology and Intensive Care, {dagger}Orthopedics; and {ddagger}Institute of Medical Biometry, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany.

Anesth Analg 2006;103:1311-1317

 

背景:柱融合术可导致严重的术后疼痛,妨碍康复。我们用一项前瞻、双盲、随机对照的研究比较了病人自控硬膜外镇痛(PCEA)与病人自控静脉镇痛(PCIA)的有效性。方法:在腰椎前-后融合术术中放置硬膜外导管后,72位病人使用了PCEA(罗哌卡因0.125%和舒太尼1.0µg/mL,输注速度14mL/h,单次剂量5mL,锁定时间15min)和静脉安慰剂或者PCIA(吗啡2.0mg/mL,单次剂量3mg,锁定时间15min)和硬膜外安慰剂。评估疼痛水平(视觉模拟评分 0-10)、活能(翻身、站立和行走)、镇痛药消耗量以不良反应至术后72h结果:按照事先确定的标准,14位病人被排除,剩下58位病人进行数据分析。在整个研究阶段内,PCEA组病人在休息和活时的疼痛水平均明显低于PCIA组病人(所有病例P < 0.0001)。PCEA组病人能在翻身的时间较早(P < 0.05)。PCEA病人对疼痛治疗满意度更高(P < 0.01)。结论:我们结论是,在柱融合术后,利用术中放置的硬膜外导管,使用罗哌卡因和舒太尼行PCEA相比PCIA能提供更好的镇痛和更高的病人满意度。

(颜涛 译, 马皓琳 李士通 校)

BACKGROUND: Spinal fusion surgery causes severe postoperative pain, hampering reconvalescense. We investigated the efficacy of patient-controlled epidural analgesia (PCEA) in a prospective, double-blind, randomized, controlled comparison with patient-controlled IV analgesia (PCIA).

METHODS: After lumbar anterior-posterior fusion receiving an epidural catheter intraoperatively, 72 patients were given either PCEA (ropivacaine 0.125% and sufentanil 1.0 µg/mL at 14 mL/h; bolus: 5 mL; lockout time: 15 min) and IV placebo or PCIA (morphine 2.0 mg/mL; bolus: 3 mg; lockout time: 15 min) and epidural placebo. Pain levels (visual analog scale 0-10), functional capabilities (turning in bed, standing, and walking), analgesic consumption, and side effects were evaluated until 72 h after surgery.

RESULTS: Fourteen patients were excluded by predetermined criteria, leaving 58 patients for data analysis. Pain levels at rest and during mobilization were significantly lower in the PCEA when compared with that in the PCIA group throughout the study period (P < 0.0001 in all cases). Time until able to turn in bed was achieved earlier in the PCEA group (P < 0.05). Patients in the PCEA group were significantly more satisfied with pain therapy (P < 0.01).

CONCLUSION: We conclude that PCEA with ropivacaine and sufentanil, using intraoperatively placed epidural catheters, provides superior analgesia and higher patient satisfaction when compared with PCIA after spinal fusion surgery.

 

冠脉旁路移植手术中使用足量酞酶:围手术期药物治疗与患者预后分析

Full-Dose Aprotinin Use in Coronary Artery Bypass Graft Surgery: An Analysis of Perioperative Pharmacotherapy and Patient Outcomes

David Royston, FRCA*, Jerrold H. Levy, MD{dagger}, Jane Fitch, MD{ddagger}, Wulf Dietrich, MD, Simon C. Body, MBChB, MPH||, John M. Murkin, MD¶, Bruce D. Spiess, MD#, and Andrea Nadel, PhD**

From the *Department of Anesthesia, Harefield Hospital, London, UK; {dagger}Department of Anesthesiology, Emory University, Atlanta, Goergia; {ddagger}Department of Anesthesiology, University of Oklahoma, Oklahoma City, Oklahoma; Department of Anesthesiology, German Heart Center Munich, Munich, Germany; ||Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; ¶Department of Anesthesia, University of Western Ontario, London, Ontario, Canada; #Department of Anesthesiology, VCURES Shock Center, Virginia Commonwealth University/Medical College of Virginia Campus, Richmond, Virginia; and **Global Statistics, Bayer Pharmaceuticals Corporation, West Haven, Connecticut.

Anesth Analg 2006 103: 1082-1088

 

背景:不恰当地激活止血和炎症反应可能与术后发病率和死亡率相关。既往实验室研究和物试验研究表明丝氨酸蛋白酶制剂——酞酶——可以预防组织和器官损伤。在这篇回顾分析中,我们评估了人类冠脉旁路移植手术(CABG)中使用酞酶治疗与器官能不全的关系。方法:使用评估足量酞酶(负荷剂量为2×109 IU,之后泵推初始剂量为2×109 IU,维持剂量为0.5×109 IU/h)减少行CABG患者(安慰剂组,n861;酞酶组,n862)术中血液丢失和输血量的安全性和有效性的前瞻性随机双盲安慰剂对照研究的资料进行回顾性分析。原始研究终点是死亡、不良的脑血管事件、心肌梗塞(MI)与药物干预(正性肌药物、血管活性药物与心律失常药物)。结果:单一变量分析显示与安慰剂相比,足量酞酶治疗对减少不良的脑血管事件的发生(比值比[OR] 0.4295%可性区间[CI] 0.19-0.93P = 0.03)和正性肌药物(OR 0.7995% CI 0.65-0.97P = 0.02)、血管活性药物(OR 0.7495% CI 0.61-0.90P < 0.01)与心律失常药物(OR 0.7995% CI 0.65-0.96P = 0.02)有明显的作用,但与死亡(OR 1.0095% CI 0.54-1.85P = 1.0)和心肌梗塞(OR 0.9295% CI 0.64-1.31P = 0.6)无关。多变量分析证明了单一变量分析的结果。结论:这项回顾性分析研究利用了行CABG患者的前瞻性随机双盲安慰剂对照研究的数据,结果表明使用全量酞酶可以降低不良的脑血管事件的发生率、减少血管活性药物的使用;但对死亡和围手术期心肌梗塞的危险性没有影响。

(金琳 译,薛张纲 审校)

BACKGROUND: Inappropriate activation of hemostasis and inflammation may contribute to postoperative morbidity and mortality. The serine protease inhibitor, aprotinin, has been shown to prevent tissue and organ injury in laboratory and animal studies. In this retrospective analysis, we evaluated the relationship of aprotinin therapy with organ dysfunction in humans undergoing coronary artery bypass graft surgery (CABG).METHODS: Data from prospective randomized, double-blind, placebo-controlled studies evaluating the safety and efficacy of full-dose aprotinin (2 million KIU load, 2 million KIU pump prime, and 0.5 million KIU/h continuous infusion) to reduce blood loss and transfusion requirements in patients undergoing CABG (placebo, n = 861; aprotinin, n = 862) were examined retrospectively. Primary end-points were death, adverse cerebrovascular outcome, myocardial infarction (MI), and pharmacological interventions (inotropic drugs, vasopressors, and antiarrhythmics). RESULTS: Univariate analysis showed that relative to placebo, full-dose aprotinin therapy was associated with significant effects on the incidence of adverse cerebrovascular outcome (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.19–0.93; P = 0.03) and use of inotropic drugs (OR 0.79, 95% CI 0.65–0.97; P = 0.02), vasopressors (OR 0.74, 95% CI 0.61–0.90; P < 0.01), and antiarrhythmics (OR 0.79, 95% CI 0.65–0.96; P = 0.02), but not death (OR = 1.00, 95% CI 0.54–1.85; P = 1.0) or MI (OR 0.92, 95% CI 0.64–1.31; P = 0.6). Multivariate analysis confirmed results of univariate analysis. CONCLUSIONS: This retrospective analysis of data collected from prospective, randomized, placebo-controlled studies in CABG shows that full-dose aprotinin use was associated with a lower risk of adverse cerebrovascular outcomes and a reduced need for use of vasoactive drugs; the risk of death and perioperative MI was not affected by aprotinin therapy.

 

 

择期行心脏外科手术的ASA III-IV患者术前口服碳水化合物

Preoperative Oral Carbohydrate Administration to ASA III-IV Patients Undergoing Elective Cardiac Surgery

Breuer, Jan-P. MD *; von Dossow, Vera MD *; von Heymann, Christian MD *; Griesbach, Markus MD *; von Schickfus, Michael Cand med *; Mackh, Elise Cand med *; Hacker, Cornelia Cand med *; Elgeti, Ulrike MD +; Konertz, Wolfgang MD +; Wernecke, Klaus-D. PhD ++; Spies, Claudia D. MD *

From the *Department of Anesthesiology and Intensive Care Medicine, Campus Charite Mitte and Campus Virchow-Klinikum; +Department of Cardiovascular Surgery; and ++Institute of Medical Statistics and Biometry, Campus Charite Mitte, CHARITE University Medicine Berlin, Berlin, Germany

Anesthesia & Analgesia. 103(5):1099-1108, November 2006

 

在这项研究中,我们调查研究了择期行心脏外科手术ASA体格态III-IV的患者术前口服碳水化合物对术后胰岛素(PIR)、胃液容量、术前不适合和器官机能障碍的影响,其中包括非胰岛素依赖2型糖尿病患者。外科手术前,188患者随机接受清澈的12.5%碳水化合物饮品(CHO)、有滋味的水(安慰剂),或整夜禁食(对照)。CHO和安慰剂采用双盲的方法在夜间给予800ml和术前2小时给予400ml相应的饮品。患者从全麻诱导开始到手后24小时予以监测。控制血糖≤10.0mmol/L的外用胰岛素需要量作为PIR的标示。胃液容量通过被胃引流(passive gastric reflux)来测量,术前不适使用目视评分表来评价。记录术后临和外科数据。血糖水平和胰岛素需要量各组之间无差别。患者接受CHO和安慰剂与对照组相比更少出现口渴症(分别为,P < 0.01 P = 0.06)。饮用液体不引起胃容量增或其他副作用。术中CHO组在心肺转流术开始后较少需要收缩性支持((P < 0.05)。结论是,在心脏外科手术之前使用碳水化合物对PIR无影响。清澈的液体减少患者口渴,而且是对于ASA III-IV的患者是安全可推荐的方法。进一步的研究将是探讨术前口服CHO可能的心脏保效应。

(孙敏莉译 薛张纲校)

In this study we investigated the effects of preoperative oral carbohydrate administration on postoperative insulin resistance (PIR), gastric fluid volume, preoperative discomfort, and variables of organ dysfunction in ASA physical status III-IV patients undergoing elective cardiac surgery, including those with noninsulin-dependent Type-2 diabetes mellitus. Before surgery, 188 patients were randomized to receive a clear 12.5% carbohydrate drink (CHO), flavored water (placebo), or to fast overnight (control). CHO and placebo were treated in double-blind format and received 800 mL of the corresponding beverage in the evening and 400 mL 2 h before surgery. Patients were monitored from induction of general anesthesia until 24 h postoperatively. Exogenous insulin requirements to control blood glucose levels <=10.0 mmol/L were used as a marker for PIR. Gastric fluid volume was measured by passive gastric reflux and preoperative discomfort using visual analog scales. Postoperative clinical and surgical data were recorded. Blood glucose levels and insulin requirements did not differ between groups. Patients receiving CHO and placebo were less thirsty compared with controls (P < 0.01 and P = 0.06, respectively). Ingested liquids did not cause increased gastric fluid volume or other adverse events. The CHO group required less intraoperative inotropic support after initiation of cardiopulmonary bypass weaning (P < 0.05). In conclusion, preoperative CHO administration before cardiac surgery does not affect PIR. Clear fluids reduce thirst and may be recommended as a safe procedure in ASA III-IV patients. Further research is indicated to investigate possible cardioprotective effects of preoperative CHO intake.

 

 

臼齿后空间大小对小儿腭面外科手术放置经口气管插管的评估

An evaluation of the retromolar space for oral tracheal tube placement for maxillofacial surgery in children.

Arora S, Rattan V, Bhardwaj N

Department of Anaesthesia and Intensive Care, Oral Health Sciences Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.

Anesth Analg. 2006 Nov;103(5):1122-5. 

 

背景:第一二恒臼齿的萌出可能影响臼齿后空间的大小。本研究我们评估了小儿臼齿后空间大小对臼齿后气管导管的放置是否充足和第一二横臼齿对此空间的影响。方法:评估3-15岁行非面部手术的患儿臼齿后空间大小。标准经口气管插管后,移气管导管至臼齿后空间,下颌缓慢闭合至中央合拢。同时注意是否有气道阻增和氧饱和度降低。研究的第二部分是经臼齿后气管插管在小儿腭面外科行术中颌间固定术的可行性评估。结果:臼齿后空间足够用来放置气管导管。第一二恒臼齿的萌发不影响气管插管。在80个臼齿后放置气管导管的患儿中间有79例可达到牙齿中央闭合。6例行颌间固定术和腭面外科手术的患儿成地进行了臼齿后气管插管。结论:臼齿后空间可安全的用于术中颌间固定患儿的气管插管,同时可让出更多的鼻腔和口腔的空间。

(吴德华译 薛张纲校)

BACKGROUND: The eruption of the first and second permanent molar teeth may influence the size of the retromolar space. In this study we evaluated the adequacy of the retromolar space for retromolar intubation and any effect of eruption of the first and second permanent molar teeth on this space in children. METHODS: Children 3-15 yr of age, undergoing surgery other than facial surgery were included for evaluation of the retromolar space. After standard oral tracheal intubation, the endotracheal tube was shifted to the retromolar space and the mandible was slowly closed to achieve centric occlusion. At the same time, any increase in airway resistance or decrease in oxygen saturation was noted. In the second part of the study, the feasibility of retromolar intubation in pediatric patients undergoing maxillofacial surgery with intraoperative maxillomandibular fixation was assessed. RESULTS: There was enough space for endotracheal tube placement in the retromolar region. The eruption of the first and second permanent molar teeth did not affect intubation. It was possible to achieve centric occlusion in 79 of 80 children with the endotracheal tube positioned in the retromolar space. Retromolar intubation was successfully accomplished in six pediatric patients undergoing maxillomandibular fixation and maxillofacial surgery. CONCLUSION: The retromolar space can be safely used for intubation in children when intraoperative maxillomandibular fixation, and simultaneous access to the nose and oral cavity are needed.

 

 

脉转流手术后的段性室壁运异常提示心肌缺血

Segmental wall-motion abnormalities after an arterial switch operation indicate ischemia

Kathryn Rouine-Rapp, Kenneth P. Rouillard, Wanda Miller-Hance, Norman H. Silverman, Kathryn K. Collins, Michael K. Cahalan, Alan Bostrom, and Isobel A. Russell

Department of Anesthesia, University of California-San Francisco, 94143-0648, USA. Anesth Analg 2006 103: 1139-1146.

 

我们前瞻性地选择了29名行脉转接手术的新生儿,研究异常的段性壁运(SWMA) 是否代表了心肌缺血。术中,经食管超声心图在基线时测定一次,心肺转流后测定两次。分别在胸骨开前和主脉钳松开后3, 6, 12, 24, 4872小时测定心肌肌钙蛋白(cTnI)水平。

术后即时Holter15导联心电图(ECG)用于评价缺血。出院前进行经食管超声心图评价。转流结束,给予鱼精蛋白后即时,9名新生儿的段性壁运正常,20名异常。其中,5名新生儿的SWMA是暂时的,另外15名出现在关胸时。后者相关的段多于前者(P > 0.001)。关胸时出现SWMA的新生儿,术后cTnI水平高于正常壁运的新生儿(P = 0.02)26名新生儿均获得了术后心电图数据。心电图显示:8名壁运正常的新生儿中的2名、5名出现暂时SWMA中的1名、13名关胸时出现SWMA中的9名,存在心肌缺血。12, 24 48 hCtnI水平术中SWMA均可预测术后SWMA。我们认为,这些数据提示了持续至脉转接术结束的SWMA出现于多个心肌段的SWMA,与心肌缺血有关。需要对这些患者进行进一步随访以明确术中心肌缺氧的增是否与长期预后有关。

(王丽珺译 薛张纲校)

We prospectively studied 29 consecutive neonates undergoing an arterial switch operation to determine if segmental wall motion abnormalities (SWMA) represented myocardial ischemia. Intraoperative transesophageal echocardiogram was recorded at baseline and twice after cardiopulmonary bypass. Cardiac troponin I (cTnI) levels were measured before sternal incision and 3, 6, 12, 24, 48, and 72 h after removal of the aortic cross-clamp. Immediate postoperative Holter and 15-lead electrocardiograms (ECG) were evaluated for ischemia. Transthoracic echocardiograms were obtained before hospital discharge. At bypass termination, immediately after protamine administration, segmental wall motion was normal in nine neonates and abnormal in 20. SWMA were transient in five and present at the time of chest closure in 15 neonates. Neonates in whom SWMA were present at chest closure had more segments involved than those in whom SWMA were transient (P > 0.001). Neonates with SWMA at chest closure had higher cTnI levels postoperatively versus neonates with normal wall motion (P = 0.02). Postoperative ECG data were available in 26 neonates. There was ECG evidence of myocardial ischemia in two of eight neonates with normal wall motion, one of five with transient SWMA, and nine of 13 with SWMA at chest closure. CTnI levels at 12, 24, and 48 h and intraoperative SWMA were predictive of postoperative SWMA. We believe these data indicate that SWMA, which persist at the completion of an arterial switch operation, and which are present in multiple myocardial segments, correlate with myocardial ischemia. Further follow-up of these patients is needed to determine if increased intraoperative myocardial ischemia correlates with long-term outcomes.

 

 

用听觉诱发电位和脑电图评价右旋美托咪啶/雷米太尼和咪达唑仑/雷米太尼对健康人轻到中度镇静的效果

The effects of dexmedetomidine/remifentanil and midazolam/remifentanil on auditory-evoked potentials and electroencephalogram at light-to-moderate sedation levels in healthy subjects.

Haenggi M, Ypparila H, Hauser K, Caviezel C, Korhonen I, Takala J, Jakob SM.

Department of Intensive Care Medicine, University Hospital of Bern, Bern, Switzerland.

Anesth Analg 2006 103: 1163-1169.

 

避免过度镇静是ICU病人的一个重要问题。电生理检测也许能解决这个问题。既然脑电图能反映不同的镇静深度,我们用它来评估10个健康病人对两种镇静药的反应。右旋美托咪啶/雷米太尼和咪达唑仑/雷米太尼被隔7天输注,分段给药,以达到234度镇静,并分别用脑电图,BISERP来监测。右旋美托咪啶/雷米太尼组的脑电图以象征深度镇静的高能低频的波形为特征。只有右旋美托咪啶/雷米太尼组的BIS值均一地下降,从94+/- 358 +/- 14,而咪达唑仑/雷米太尼组的BIS值从94 +/- 2 76 +/- 10。咪达唑仑/雷米太尼组的ERP5.3 +/- 1.3 0.4 +/- 1.1。我们得出结论:用右旋美托咪啶/雷米太尼镇静的志愿者,其ERP值表明其对听觉刺激有皮质反应,即使其镇静深度已很深。ERP能反映咪达唑仑的镇静深度但不能反映右旋美托咪啶的镇静深度。BIS则能反映右旋美托咪啶的镇静深度但不能反映咪达唑仑的镇静深度。

(钟静译 薛张纲校)

Avoidance of excessively deep sedation levels is problematic in intensive care patients. Electrophysiologic monitoring may offer an approach to solving this problem. Since electroencephalogram (EEG) responses to different sedation regimens vary, we assessed electrophysiologic responses to two sedative drug regimens in 10 healthy volunteers. Dexmedetomidine/remifentanil (dex/remi group) and midazolam/remifentanil (mida/remi group) were infused 7 days apart. Each combination of medications was given at stepwise intervals to reach Ramsay scores (RS) 2, 3, and 4. Resting EEG, bispectral index (BIS), and the N100 amplitudes of long-latency auditory-evoked potentials (ERP) were recorded at each level of sedation. During dex/remi, resting EEG was characterized by a recurrent high-power low-frequency pattern which became more pronounced at deeper levels of sedation. BIS Index decreased uniformly in only the dex/remi group (from 94 +/- 3 at baseline to 58 +/- 14 at RS 4) compared to the mida/remi group (from 94 +/- 2 to 76 +/- 10; P = 0.029 between groups). The ERP amplitudes decreased from 5.3 +/- 1.3 at baseline to 0.4 +/- 1.1 at RS 4 (P = 0.003) in only the mida/remi group. We conclude that ERPs in volunteers sedated with dex/remi, in contrast to mida/remi, indicate a cortical response to acoustic stimuli, even when sedation reaches deeper levels. Consequently, ERP can monitor sedation with midazolam but not with dexmedetomidine. The reverse is true for BIS.

 

 

机械通气时脉血压和光学体积描记的变化

Variations in Arterial Blood Pressure and Photoplethysmography During Mechanical Ventilation

Giuseppe Natalini, Antonio Rosano, Maria E. Franceschetti, Paola Facchetti, and Achille Bernardini

From the Department of Anesthesia, Intensive Care and Emergency, Poliambulanza Hospítal, Brescí, Italy.

Anesth Analg 2006 103:1182-1188

 

我们分析了机械通气引起的脉血压变化和从监测在手术室和重症监室里的57位病人的波形得来的光学体积描记图。分析在正压通气时的收缩压和脉压变化,{Delta}Up, {Delta}Down,在脉和光学体积描记波形中的喷射前变化在49(86%)个病人中存在。当同时使用脉血压和光学体积描记图来计算时,脉搏压变化和喷射前期相似,否则两者的变化则不同。光学体积描记图的脉搏变化〉9%说明患者的脉压变化〉13%ROC曲线下面积=0.85)或{Delta}Down >5 mm Hg ( ROC 曲线下面积 = 0.85)。在低血压的患者中,光学体积描记图的脉搏变化〉9%仍然是最佳的域值(脉压变化>13%ROC曲线下面积=0.90{Delta}Down >5 mm HgROC曲线下面积=0.93)来预计液体反应性。总之,这项研究显示了在脉压波形中观察到的脉搏变化和光学体积描记图在对正压机械通气的反应是相似的。而且,光学体积描记图的脉搏变化>9%显示了机械通气导致脉压变化的患者可能对液体管理有反应。

(周 荻译 薛张纲校)

We analyzed ventilation-induced changes in arterial blood pressure and photoplethysmography from waveforms obtained by monitoring 57 patients in the operating room and intensive care unit. Analysis of systolic and pulse pressure variations during positive pressure ventilation, {Delta}Up, {Delta}Down, and changes in the preejection period on both arterial and photoplethysmographic waveforms were possible in 49 (86%) patients. The pulse pressure variation and preejection period were similar when calculated using both arterial blood pressure and photoplethysmography, whereas the other variables were different. Photoplethysmographic pulse variation >9% identified patients with arterial pulse pressure variation >13% (area under ROC curve = 0.85) or {Delta}Down >5 mm Hg (area under ROC curve = 0.85). In hypotensive patients, photoplethysmographic pulse variation >9% remained the best threshold value (pulse pressure variation >13%: area under ROC curve = 0.90; {Delta}Down >5 mm Hg: area under ROC curve = 0.93) for predicting fluid responsiveness. In conclusion, this study showed that pulse variations observed in the arterial pressure waveform and photoplethysmogram are similiar in response to positive pressure ventilation. Furthermore, photoplethysmographic pulse variation > 9% identifies patients with ventilation-induced arterial blood pressure variation that is likely to respond to fluid administration.

 

 

气管内注气通气对气体交换效率的影响

The Effect of Tracheal Gas Insufflation on Gas Exchange Efficiency

Michael R. Pinsky, MD*{dagger}, Edgar Delgado, RRT{ddagger}, and Bernard Hete, PhD

Department of Critical Care Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261.

Anesth Analg 2006;103:1213-1218

 

经气管的注气通气法(TGI)可以改善气体交换的效率,但同时会伴有肺的过度膨胀,通常需要调整呼吸机来代偿增的气体流量。虽然双向TGI (Bi-TGI)将肺的过度膨胀减到最少,但它还是需要降低潮气量预防肺的过度膨胀。由Respironics (Murrysville, PA)发明的一种流量代偿系统可以匹配TGI的流量,然而,两者的效率都没有在活体中得到证实。我们验证假设:流量代偿可以使用一个不变的分钟通气量;Bi-TGI比非双向TGI(Uni-TGI)产生更少的过度膨胀,在TGI期间气管导管的大小会影响过度膨胀的程度。我们研究七只麻醉的狗,用Respironics的流量代偿系统进行正压通气。在持续稳定情况下进行测量,同时监测CO2 的产生。气体交换效率(通过测量呼出气体)和过度膨胀(通过测量胸腔压的增)在Bi-TGI Uni-TGI7 10F的气管导管之间比较。在有流量代偿系统下,Bi-TGI Uni-TGI可以不改变分钟通气量。在各大小的气管导管中,Uni-TGIBi-TGI产生更多的过度膨胀。7.5F以的气管导管普遍产生过度膨胀。我们得出结论,这种新的流量代偿系统使TGI在使用中不需要调整呼吸参数,并且Bi-TGIUni-TGI产生更少的过度膨胀,在小直径的气管导管中也是如此。

(陆文清译 薛张纲校)

Transtracheal gas insufflation (TGI) improves gas exchange efficiency, but is associated with hyperinflation, and usually requires ventilator adjustment to compensate for the increased gas flow. Although bidirectional TGI (Bi-TGI) minimizes hyperinflation, it does not preclude the need to reduce tidal volumes to prevent hyperinflation. A flow-compensation system was developed by Respironics (Murrysville, PA) to match TGI flows; however, neither that nor the efficacy of Bi-TGI have been tested in vivo. We tested the hypotheses that flow compensation allows for a constant minute ventilation; Bi-TGI produces less hyperinflation than does unidirectional TGI (Uni-TGI), and endotracheal tube size influences the degree of hyperinflation during TGI.Seven anesthetized intact dogs were studied during positive-pressure ventilation using the Respironics flow compensation system. Measurements were made during steady-state conditions at constant and measured levels of CO2 production. Gas exchange efficiency (assessed by expired gas analysis for dead space) and hyperinflation (measured as an increase in pleural pressure) were compared during Bi- and Uni-TGI and for endotracheal tube sizes varying from 7 to 10F. Bi- and Uni-TGI could be delivered at constant minute ventilation without adjusting ventilatory setting when the flow compensation circuit was present. Uni-TGI produced more hyperinflation than did Bi-TGI with all sizes of endotracheal tube, and hyperinflation was universally present as tube size decreased to 7.5F. We conclude that this new flow compensation system allows for the delivery of TGI without the need for adjustments to the ventilator settings, and that Bi-TGI produces less hyperinflation than does Uni-TGI, even with small diameter endotracheal tubes.

 

 

CT估测非挫伤脑区比重在外伤性脑损伤中作为严重程度的标志

Computed tomography-estimated specific gravity of noncontused brain areas as a marker of severity in human traumatic brain injury

Degos V, Lescot T, Zouaoui A, Hermann H, Preteux F, Coriat P, Puybasset L.

Department of Anesthesiology and Critical Care, Centre Hospitalo-Universitaire (CHU) Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris, France.

Anesth Analg. 2006 Nov;103(5):1229-36.

 

在这项研究中,我们评估了外伤性脑损伤(TBI)患者中脑估测比重和临症、治疗强度水平结局的关系。在120名严重TBI患者中用初始CT5 +/- 6 h) DICOM影像测定了非挫伤球脑重量、体积、和eSG。由40名健康患者中得到对照值。TBI患者非挫伤球脑区的eSG明显高于对照组。Marshall CT分级34级,或起初的Glasgow昏迷评分较低的患者eSG更高。根据非挫伤球区eSG分两个组:小于(n = 83, 69%) 或大于 (n = 37, 31%)正常阈值(确定为1.96 sd above normal = 1.0355 g/mL)。eSG增组中发生瞳孔散大、事故现场应用渗透治疗、和治疗强度水平更高。eSG增高的病人出ICU时的结局更差,而一年时的差异无显著性。CT分析eSGTBI早期管理中的作用可能是切实可行的。

(徐丽颖译 薛张纲校)

In this study, we assessed the relationship between brain estimated specific gravity (eSG) and clinical symptoms, therapeutic intensity level, and outcome in human traumatic brain injury (TBI). Brain weight, volume, and eSG of the noncontused hemispheric areas were measured from computed tomography (CT) DICOM images on the initial (5 +/- 6 h) CT of 120 patients with severe TBI. Control values were obtained from 40 healthy patients. The eSG of the noncontused hemispheric areas was significantly higher in TBI patients than in controls. eSG was higher in patients having a Marshall CT classification of 3 or 4 or a low initial Glasgow coma score. Two groups were defined according to the eSG of the noncontused hemispheric areas: less than (n = 83, 69%) or more than (n = 37, 31%) the threshold of normality (defined as 1.96 sd above normal = 1.0355 g/mL). The occurrence of mydriasis, use of osmotherapy at the scene of the accident, and therapeutic intensity level were higher in the increased eSG group. The outcome at intensive care unit discharge was worse in patients with an increased eSG although the difference was no longer significant at 1 yr. eSG determination by CT analysis might be relevant in the early management of TBI.

 

 

头颈部过伸可增Mallampati气道评估的特异性和预测价值

Craniocervical Extension Improves the Specificity and Predictive Value of the Mallampati Airway Evaluation

George A. Mashour and Warren S. Sandberg

Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, USA.

Anesth Analg 2006 103: 1256-1259.

 

研究背景:改良的Mallampati(MMP)分级是评估张口度和口腔内结构的标准气道检查.最近的数据指出最大张口度(通过齿间距来测定)出现在头颈过伸时.MMP检查时患者头呈中立位,未达到最大齿间距,故气道条件会显得差一些.我们设想在MMP评分中增头颈过伸,它与传统的MMP检查相比是否会增张口度,降低评分以减少假阳性率.方法:数名有着至少1年气道管理经验的临医生采用MMP检查(被检查者头呈中立位)评估60位成人的气道条件.同样的检查在入颈部过伸(EMS)后重复一次.结果:总体而言,头颈过伸降低了MMP分级(p<0.002).EMS和传统的MMP相比使特异性从70%增到80%,阳性预测值从24%增到31%.两者的灵敏度相同(83%).结论:头颈过伸可增MMP气道评估的特异性和阳性预测值,但灵敏度不变.应当考虑将EMS引入到临实践中.

(王慧琳译 薛张纲校)

BACKGROUND: The modified Mallampati (MMP) classification is a standard airway examination that assesses mouth opening and structures within the oral cavity. Recent data suggest that maximal mouth opening (as measured by interdental distance) is possible only with extension of the craniocervical junction. Because the MMP examination is performed with the head in a neutral position, the airway may appear worse because of submaximal interdental distance. We hypothesized that adding craniocervical extension to the MMP would allow for greater mouth opening, lower scores, and less false positives than the traditional MMP examination. METHODS: Multiple clinicians with at least 1 yr of airway experience evaluated adult airways (n = 60) with the MMP examination (with head in neutral position). The same examination was then repeated with the addition of craniocervical extension (Extended Mallampati Score, EMS). RESULTS: On average, craniocervical extension decreased the MMP class (P < 0.002). The EMS improved specificity from 70% to 80% and positive predictive value from 24% to 31% when compared with the traditional MMP. The sensitivity (83%) was the same for MMP and EMS. CONCLUSIONS: Craniocervical extension improves the specificity and positive predictive value of the MMP airway evaluation while retaining sensitivity of the traditional MMP examination. The introduction of the EMS into clinical practice should be considered.

 

 

20°头高位能减少甲腺手术后恶心呕吐的发生率和严重程度

The twenty-degree reverse-Trendelenburg position decreases the incidence and severity of postoperative nausea and vomiting after thyroid surgery.

Tominaga K, Nakahara T.

Department of Anesthesiology, Tokushima Municipal Hospital, Tokushima, Japan. Anesth Analg. 2006 Nov;103(5):1260-3

 

研究背景:在这个随机、单盲、控制实验中,我们评价了20°头高位对甲腺手术后恶心呕吐的作用。方法:病人(n = 224)给与标准的异丙酚全麻。在整个手术过程中,病人被随机的分为两组:一组为头过伸位20°头高位,另一组为头过伸位水平位。术后24小时所有的不良事件将被记录包括术后恶心、呕吐、恶心程度评分、呕吐次数止吐药物的使用次数。我们将这段时间分为0-3小时、3-24小时两个阶段。结果:在术后0-3小这个时间段内两组的不良事件是可比的。但在20°头高位组不论是在3-24小时还是整个术后24小时,恶心和/或呕吐,恶心程度评分,呕吐次数都显著下降。结论:20°头高位能改善术后恶心呕吐。

(王慧琳译 薛张纲校)

BACKGROUND: In this randomized, single-blind, controlled study, we evaluated whether the 20 degrees reverse-Trendelenburg position had an effect on postoperative nausea and vomiting in patients undergoing thyroid surgery. METHODS: Patients (n = 224) were given a standardized propofol anesthetic. Intraoperatively, patients were randomly assigned into two groups according to the tilt of the table maintained during surgery: patients were positioned with the neck extended and the table tilted with 20 degrees reverse-Trendelenburg or with the neck extended and the table positioned at a horizontal tilt. All episodes of postoperative nausea, vomiting, nausea severity score, frequency of vomiting, and the use of antiemetics were recorded during the first 24 h after anesthesia. We divided this time period into 0-3 h and 3-24 h. RESULTS: During the 0-3 h postoperative period, all observed episodes were comparable between groups. However, during the 3-24 h and the overall postoperative period, the incidence of nausea and/or vomiting, the nausea severity score, and frequency of vomiting were significantly less in the 20 degrees reverse-Trendelenburg position. CONCLUSION: The 20 degrees reverse-Trendelenburg position effectively ameliorates postoperative nausea and/or vomiting.

 

 

经斜角肌间沟臂丛神经阻滞行肩关镜手术病人术前给予单次剂量巴喷丁(800mg)不能增术后镇痛效果

A Single Preoperative Dose of Gabapentin (800 Milligrams) Does Not Augment Postoperative Analgesia in Patients Given Interscalene Brachial Plexus Blocks for Arthroscopic Shoulder Surgery

Frédéric Adam, MD*, Christophe Ménigaux, MD*, Daniel I. Sessler, MD{dagger}{ddagger}, and Marcel Chauvin, MD

From the *Department of Anesthesia, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris; {dagger}Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio; {ddagger}Outcomes Research Institute, University of Louisville, Louisville, KY; and Department of Anesthesia and INSERM E 332, Hôpital Ambroise Paré.

Anesth Analg 2006 103: 1278-1282.

 

背景:肩关镜手术后镇痛不足比较常见。在多种情况下,同时行斜角肌间沟阻滞和给予巴喷丁石是治疗疼痛的有效方法。我们检验在门关镜手术中通过斜角肌间沟臂丛神经阻滞并给予巴他丁是否可以增术后镇痛效果。方法:60例病人随机分为两组,于术前2小时通过口服分别给予巴他丁800mg和安慰剂。然后用0.5%罗哌卡因0.3mL/kg行经斜角肌间沟臂丛神经阻滞。全麻维持采用七氟烷,并给予单次剂量瑞太尼1µg/kg。术后镇痛起始给予吗啡,随后给予可多普洛菲(150mg口服,每日两次),需要时合并使用对乙酰氨基酚400mg和右丙氧30mg。疼痛评分、镇痛需求和副作用在门手术室和家中观察48小时。结果:全麻后苏醒时间两组相似。两组间在疼痛评分、首次术后镇痛要求和口服镇痛药的用量方面也无显著差别。除了巴他丁组头痛发生率稍低以外,两组间副作用的发生率也基本相当。结论:术前单次给予巴他丁800mg不能增在经斜角肌间沟臂丛神经阻滞下行肩关镜手术病人的术后镇痛效果。

(金 路译 薛张纲校)

BACKGROUND: Inadequate analgesia is common after shoulder arthroscopy. Both interscalene blocks and gabapentin are effective methods of pain management under various circumstances. We tested the hypothesis that gabapentin augments postoperative analgesia provided by interscalene brachial plexus block in patients having ambulatory arthroscopic shoulder surgery. METHODS: Sixty patients were randomly assigned to receive oral gabapentin, 800 mg, or placebo 2 h before surgery. An interscalene brachial plexus block with 0.3 mL/kg of 0.5% ropivacaine was performed. General anesthesia was maintained with sevoflurane and included a single 1-µg/kg dose of remifentanil. Postoperative analgesia was initially provided with morphine and subsequently with ketoprofene (150 mg orally twice daily) and a combination of 400 mg acetaminophen and 30 mg dextropropoxyphene as needed. Pain scores, analgesic requirements, and side effects were assessed in the ambulatory unit and at home for 48 h. RESULTS: Emergence from general anesthesia was similar in both groups. There were no significant differences in pain scores, first postoperative request for analgesia, or oral analgesic consumption. The incidence of side effects was comparable in both groups, except that headaches were less frequent in the gabapentin group. CONCLUSION: A single preoperative dose of gabapentin (800 mg) does not augment postoperative analgesia in patients given interscalene brachial plexus blocks for arthroscopic shoulder surgery.

 

 

三维核磁共振影像用于人类腰段脑液容量的测定

Lumbosacral Cerebrospinal Fluid Volume in Humans Using Three-Dimensional Magnetic Resonance Imaging

John T. Sullivan, Sharon Grouper, Matthew T. Walker, Todd B. Parrish, Robert J. McCarthy, and Cynthia A. Wong

From the Departments of *Anesthesiology and {dagger}Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL.

Anesth Analg 2006 103: 1306-1310

 

背景: 蛛网膜下腔麻醉的临反应与腰段脑液容量有关,它在病人中是多变的。方法:71个病人用长回声波(TE = 198 msec)、快速自旋回波程序时间来做腰段的磁性共振成像制脂肪成像。建立三维成像,腰段的CSF容量用a threshold-based region产生的运算法则来计算。结果: 用水槽法和尸体脑液来证实的实验是精确的。变异系数是0.42%。计算的平均容量是 35.8 ± 10.9ml,范

围是10.6-61.3ml。腰段CSF容量在病人中变化很大,而且与BMI成反比例。椎管狭窄做放射断的病人腰段CSF容量要比其他组小,与疝气病人相比是不同

的。结论: 这项术的应用将会使我们对于蛛网膜下腔麻醉有更深的了解。

(韩晓丹译 薛张纲校)

BACKGROUND: The clinical response to spinal anesthesia is influenced by lumbosacral cerebrospinal fluid (CSF) volume, which is highly variable among patients. METHODS: Lumbosacral magnetic resonance images were obtained in 71 patients using a long echo time (TE = 198 msec), fast spin echo sequence with fat suppression. Three-dimensional images were created and lumbosacral CSF volume was estimated using a threshold-based region growing algorithm.RESULTS: A validation experiment using a water bath and cadaveric spinal cord demonstrated that the technique was accurate (1.4 ± 0.4% difference between estimated and measured). The coefficient of variance was 0.42% among the three estimated CSF values per subject. The mean calculated volume was 35.8 ± 10.9 mL with a range of 10.6-61.3 mL. Lumbosacral CSF volume was widely variable among patients and was inversely proportional to body mass index (r = –.276, P = 0.02). Mean calculated lumbosacral CSF volumes were smaller in the group of subjects that had radiographic diagnoses of spinal stenosis when compared with subjects with no diagnosis (mean difference –8.4 mL, 95% CI of the difference, –16.1 to –0.8 mL, P = 0.03) and were not different when compared with those with herniated disk disease (mean difference –6.4 mL, 95% CI of the difference –14.7 to 1.9 mL, P = 0.19). CONCLUSIONS: Application of this technique to clinical investigations may further enhance our understanding of spinal anesthesia.

 

局部麻醉药物的心脏毒性:一项麻醉院系关于当代临实践的调查研究

Local Anesthetic-Induced Cardiac Toxicity: A Survey of Contemporary Practice Strategies Among Academic Anesthesiology Departments

Corcoran, William

Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1009, USA.
Anesth Analg 2006 103: 1322-1326

 

虽然有新的局麻药(LA) 、有效的实验剂量、还有新的局麻术提高了局部麻醉的安全性,但是由局麻药引起的心脏毒性作用仍是存在的。所以,我们评估了美国麻醉学会中对于LA引起的心脏毒性的最新处理措施。一份有19个问题的关于局麻药的调查问卷被发往135个麻醉学会。我们收到了91份匿名的文卷,占到了总数的67%。根据每个月外周神经阻滞的次数我们将应答者分组:>70 38%),517013%),315020%) 113023%),<106%)。与较低的局麻术使用组相比,在局麻例数>70的组中外周神经阻滞使用罗派卡因是低使用组的1.7倍,输注脂肪乳剂用于复苏是其3.9倍,同样,高局麻术使用组更倾向于有一套建立有创心肺复苏支持方案。我们的结论是在调察机构中对于LA引起的毒性反应的处理和准备有差别,这些差别意示着局麻药引起的安全性问题还没解决。

(韩晓丹译 薛张纲校)

Though new local anesthetics (LA), effective test-dosing, and new regional anesthetic techniques may have improved the safety of regional anesthesia, the optimal management plan for LA-induced cardiac toxicity remains uncertain. Accordingly, we evaluated current approaches to LA cardiotoxicity among academic anesthesiology departments in the United States. A 19-question survey regarding regional anesthesia practices and approaches to LA cardiac toxicity was sent to the 135 academic anesthesiology departments listed by the Society of Academic Anesthesiology Chairs-Association of Anesthesiology Program Directors. Ninety-one anonymously completed questionnaires were returned, at a response rate of 67%. The respondents were categorized into groups according to the number of peripheral nerve blocks (PNBs) performed each month: >70 PNBs (38%), 51–70 PNBs (13%), 31–50 PNBs (20%), 11–30 PNBs (23%), and <10 PNBs (6%). Anesthesia practices administering >70 PNBs were 1.7-times more likely to use ropivacaine (NS), 3.9-times more likely to consider lipid emulsion infusions for resuscitation (P = 0.008), and equally as likely to have an established plan for use of invasive mechanical cardiopulmonary support in the event of LA cardiotoxicity (NS) than low-PNB volume centers. We conclude that there are differences in the management and preparedness for treatment of LA toxicity among institutions, but the safety implications of these differences are undetermined.

 

心脏手术中大剂量肽酶的使用:如此大剂量足够吗?8281例心脏手术病人使用肽酶后的分析

High-Dose Aprotinin in Cardiac Surgery: Is High-Dose High Enough?

An Analysis of 8281 Cardiac Surgical Patients Treated with Aprotinin

Wulf Dietrich, MD, PhD*, Raimund Busley, MD*, and Monika Kriner, MSc{dagger}

From the *Department of Anesthesiology, German Heart Center Munich; and {dagger}Institute for Statistics and Epidemiology, Medical Faculty, Technical University, Munich, Germany.

Anesth Analg 2006 103: 1074-1081.

本文回顾性分析并以验证如下假设:使用大于6×106 KIU剂量的肽酶较使用5-6×106KIU肽酶更有效地减少出血。在8281例成年心脏手术病例中,肽酶的使用剂量与体重、手术时间相联系并计算每分钟每公斤使用量(KIU/Kg/Min)。确定线性和逻辑回归曲线以监测肽酶剂量与术后出血、输血量以其他因素的关系。6小时胸引流量在小剂量组(最小四分位数)为447 ± 319ml,而作为对照的大剂量组(最大四分位数)则为360 ± 290ml(p<0.01)。需要输异体血的病人比例为小剂量组55%,而大剂量组为47%。肽酶剂量也是术后开胸止血手术的一个独立危险因子(低剂量组数为2.4%,大剂量组为1.9%)。肾衰需要透析(大剂量组2.3%,低剂量组3.3%,P < 0.01)或肾损(术后肌酐升高≥2 mg/dL,大剂量组6.4%,低剂量组10%,P < 0.01)的风险在大剂量组较小。因此肽酶的剂量和肾能之间并没有关系(原文)。作者的结果证实了如下假设:心脏手术中个体化剂量偏高些的肽酶有可能更有效。

(宋翠侠 陈杰 校)

In this retrospective analysis we tested the hypothesis that aprotinin doses of more than 6 x 106 kallikrein inhibiting units (KIU) per patient may be more effective in reducing bleeding compared with the high-dose regimen of 5–6 x 106 KIU aprotinin. The aprotinin doses administered for 8281 adult cardiac surgical patients were correlated to body weight and time of operation and calculated in KIU per kg body weight and minute of operation. Linear and logistic regression models were designed to detect potential associations between dose and postoperative bleeding, transfusion, and other covariates. The 6-h chest tube drainage in the lowest quartile dosing group was 447 ± 319 mL (mean ± sd) compared with 360 ± 290 mL in the highest quartile dosing group (P < 0.001). The proportion of patients requiring allogeneic blood transfusion was reduced from 55% to 47% comparing the lowest with the highest dosing group (P < 0.01). Aprotinin dose was also an independent predictor for rethoracotomy for surgical hemostasis (1.9% in the highest quartile to 2.4% in the lowest dosing quartile; P < 0.01). The risk of renal failure requiring dialysis (2.3% in the highest dosing group vs 3.3% in the lowest dosing group; P < 0.01) or impairment of renal function (creatinine increase of 2 mg/dL postoperatively, 6.4% in the highest dosing group vs 10.0% in the lowest dosing group; P < 0.01) was lower with higher doses of aprotinin. Thus, there was no association between aprotinin dose and renal function. Our results support the hypothesis that a more individualized aprotinin regimen with potentially higher doses may optimize the effectiveness of aprotinin therapy in cardiac surgery.

 

 

左西孟旦对人乳内脉的血管扩张作用

The Vasodilatory Effects of Levosimendan on the Human Internal Mammary Artery

Félix R. Montes, MD*, Darío Echeverri, MD{dagger}, Lorena Buitrago, MB{ddagger}, Isabel Ramírez, IE, Juan C. Giraldo, MD*, Javier D. Maldonado, MD||, and Juan P. Umaña, MD||

From the Departments of *Anesthesiology, {dagger}Cardiology, ||Cardiovascular Surgery, {ddagger}Laboratory of Vascular Function, Fundación CardioInfantil, Instituto de Cardiología; and Facultad de Ingeniería Industrial, Universidad de Los Andes, Bogota, Colombia, South America.

Anesth Analg 2006 103: 1094-1098

.

背景:左西孟旦是一种强心药,能通过增强心肌钙离子敏感性而增强心肌收缩性,通过开放ATP-依赖性 K+通道引起周围血管扩张。此药能否用于冠脉旁路移植术中治疗移植血管的痉挛,目前尚不确定。

方法:观察左西孟旦对取自冠脉旁路移植术病人的乳内脉(IMA)的作用。将IMA仔细制成环,用两根金属钩固定并置于器官浴箱,并用去甲肾腺素和促凝血素 A2 同型物(U46619)使IMA环明显收缩。将硝酸甘油、米农他和左西孟旦分别作用于脉环,并绘制脉舒张浓度反应曲线。评估左西孟旦对有能性内皮的脉环和无能性内皮的脉环的作用。另外评估左西孟旦在防止去甲肾腺素诱发的脉痉挛的作用。

结果:硝酸甘油、米农和左西孟旦完全逆转了U46619和去甲肾腺素引起的IMA收缩。左西孟旦对去甲肾腺素诱发的IMA收缩能产生有效的浓度依赖性的效应。左西孟旦对有或无能性内皮的脉的作用是相似的。

(齐波 陈杰 校)

BACKGROUND: Levosimendan, an inotropic drug that enhances myocardial contractility through myofilment calcium sensitazion, induces peripheral vasodilation via opening ATP-dependent K+ channels. It is unknown whether this drug can be used for the treatment of perioperative vasospasm of arterial conduits used for coronary artery bypass grafting.

METHODS: We investigated the effects of levosimendan on human internal mammary artery (IMA) specimens taken from patients undergoing coronary artery bypass surgery. The rings were carefully prepared and placed between two wire hooks in organ bath chambers and then constricted submaximally with norepinephrine and thromboxane A2 analog (U46619). Nitroglycerin, milrinone, and levosimendan were separately added in a cumulative fashion and concentration response curves for relaxation were constructed. In parallel experiments, the response to levosimendan was evaluated on rings with and without functional endothelium. Levosimendan prevention of norepinephrine-induced contraction was also estimated.

RESULTS: Nitroglycerin, milrinone, and levosimendan completely reversed the contraction of the IMA segments induced by U46619 and norepinephrine. Levosimendan produced a potent, concentration-dependent preventive effect on the norepinephrine-induced contraction of IMA. The responses to levosimendan were similar in preparations with or without endothelium.

 

阻塞性睡眠呼吸暂停综合征患儿进行增殖腺扁桃体切除术的围术期并发症

Perioperative Complications of Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome

John C. Sanders, MB, BS, FRCA*, Melinda A. King, MD*, Ronald B. Mitchell, MD, FRCS{dagger}{ddagger}, and James P. Kelly, PhD{dagger}

From the *Departments of Anesthesiology and Critical Care, {dagger}Surgery, {ddagger}Pediatrics, University of New Mexico, School of Medicine, Albuquerque, New Mexico.

Anesth Analg 2006 103: 1115-1121.

作者评估了阻塞性睡眠呼吸暂停综合症(OSAS)患儿在进行增殖腺扁桃体切除术后发生并发症的比率,以这些患儿使用常规麻醉方式的安全性和并发症术前预测因子。61位经多导睡眠描记法所确的OSAS患儿和21位复发性扁桃体炎的患儿进行了常规标准的麻醉(年龄为216岁,ASA IIII),记录围手术期并发症的发生次数和药物治疗量,以OSAS的严重程度。术中OSAS患儿发生呼吸系统并发症的比例多于非OSAS患儿(5.72.9P<0.0001),包括麻醉诱导和苏醒时声门阻塞、呼吸暂停等是最常见的并发症。体重轻、年龄小、OSAS严重并发症的发生比例高。在麻醉苏醒恢复时给OSAS患儿药物治疗比OSAS患儿更为必要(17/611/21,P<0.05)。但是两组患儿在阿片类药物的需求和恢复室内的复苏时间方面无明显差异。述结果表明OSAS患儿在腺体样扁桃体切除术后,更易发生呼吸系统并发症,但是这些并发症并不延长他们在恢复室内的复苏时间。

(詹琼慧 陈杰 校)

We evaluated the rate of complications experienced by children who undergo adenotonsillectomy for obstructive sleep apnea syndrome (OSAS), the safety of a standard anesthetic protocol for these children, and preoperative predictors of complications. Sixty-one children with OSAS, confirmed by polysomnography, and 21 children with recurrent tonsillitis were anesthetized using a standard protocol before adenotonsillectomy (ages 2–16 yr, ASA 1–3). The number of complications and medical interventions in the perioperative period were recorded and correlated with the presence and severity of OSAS. Children with OSAS had more respiratory complications per operation than non-OSAS children (5.7 vs 2.9, P < 0.0001). Supraglottic obstruction, breath holding, and desaturation on anesthetic induction and emergence were the most common complications. Increased severity of OSAS, low weight, and young age are correlated with an increased rate of complications. Medical intervention was necessary in more children with OSAS during recovery and emergence than in the non-OSAS group (17/61 vs 1/21, P < 0.05). Both groups of children had similar opioid requirements and time to discharge from the recovery room. These findings suggest that children with OSAS are at risk for respiratory complications after adenotonsillectomy, but that these complications do not prolong the time to discharge.

 

 

小儿先天性心脏病患者使用肝素的效果以凝血酶制剂浓度的测定

Clinical Measures of Heparin’s Effect and Thrombin Inhibitor Levels in Pediatric Patients with Congenital Heart Disease

Nina A. Guzzetta, MD*, Bruce E. Miller, MD*, Kathy Todd, RN, BA, CCRC{dagger}, Fania Szlam, MMSc*, Renee H. Moore, MS{ddagger}, Keith K. Brosius, MD*, Elizabeth C. Wilson, MD*, Anna M. Cohen, MD*, and Steven R. Tosone, MD*

From the *Department of Anesthesiology, Emory University School of Medicine; {dagger}Cardiac Research Department, Children’s Healthcare of Atlanta at Egleston; and {ddagger}Department of Biostatistics, Emory University, Atlanta, Georgia.

Anesth Analg 2006 103: 1131-1138.

 

本研究中,作者研究了小儿先天性心脏病患者心肺转流期间三种凝血酶制剂:凝血酶ATⅢ),肝素辅因子HCⅡ)和α2-巨球蛋白(α2M)监测肝素效果的几种方法之间的关系。118名儿童分为6个年龄组:<1月;13月;36月;612月;1224月;和>10岁。测定ATⅢHCⅡα2M的基础浓度,同时测定硅藻土和白陶土激活的凝血酶时间(ACT)的基础值,给予标准肝素400U/kg3分钟复测。计算每个病人给予肝素前后的ACT变化和肝素的剂量-反应关系。与硅藻土相比,白陶土激活的ACT测试在其给予肝素后变异性较小。而成人的结果则相反,ATⅢ与肝素作用的临实验之间以其它凝血酶制剂间并没有正相关关系。此外,小于1月龄的病人α2M的水平意外的低,同时伴随ATⅢHCⅡ的低水平。作者的发现在于应当关注新生儿心肺转流期间肝素是否有足够的凝作用。因此,ACT延长是否真实反映其凝作用需进一步研究。

(周懿之 陈杰 校)

In this investigation, we examined the relationship among three thrombin inhibitors, antithrombin III (ATIII), heparin cofactor II (HCII), and {alpha}-2-macroglobulin ({alpha}2M), and several clinical tests of heparin’s effect in pediatric patients with congenital heart disease undergoing cardiopulmonary bypass. One hundred eighteen children were stratified into six age groups: <1 mo, 1–3 mo, 3–6 mo, 6–12 mo, 12–24 mo, and >10 yr. Baseline ATIII, HCII, and {alpha}2M values were measured. Baseline celite- and kaolin-activated clotting times (ACT) were also measured and repeated 3 min after a standard heparin dose of 400 U/kg. Differences in ACT values before and after heparin administration and a heparin dose–response relationship were calculated for each patient. Kaolin-activated ACT tests showed less variation after heparin administration than celite-activated tests. In contrast to what has been demonstrated in adults, ATIII showed no positive correlation with the clinical tests of heparin’s effect nor did the other thrombin inhibitors. Additionally, patients <1 mo old had unexpectedly low levels of {alpha}2M accompanying their expected low levels of ATIII and HCII. Our findings raise concerns about the ability of heparin to adequately anticoagulate these neonates during cardiopulmonary bypass and, consequently, challenge the accuracy of ACT prolongation to truly reflect the extent of their anticoagulation.

 

 

枢复宁和氟哌利多在预防术后恶心呕吐方面的相互作用

The Additive Interactions Between Ondansetron and Droperidol for Preventing Postoperative Nausea and Vomiting

Matthew T. V. Chan, MBBS, FANZCA*, Kai C. Choi, PhD{dagger}, Tony Gin, MD, FRCA, FANZCA*, Po Tong Chui, MBBS, FANZCA*, Timothy G. Short, MD, FANZCA{ddagger}, Pong Mo Yuen, MBChB, FRCOG, Amy H. Y. Poon, MBChB, FANZCA*, Christian C. Apfel, MD, PhD||, and Tong J. Gan, MD, FRCA

From the *Department of Anaesthesia and Intensive Care; {dagger}Centre for Epidemiology and Biostatistics; Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region; {ddagger}Department of Anaesthesia, Auckland City Hospital and Auckland School of Health Sciences, Auckland University; ||Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, California; and ¶Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2006 103: 1155-1162.

[

预防性使用枢复宁和氟哌利多能够减少术后恶心呕吐的发生率。前瞻性研究表明同时使用这两种药物所产生的止吐效果比单独使用任何一种的效果更好。作者使用一种非参数的方法来证明枢复宁和氟哌利多之间的相互作用是否具有可性,并且比较二者的混合制剂的实际作用和预期值(两种药物的单独作用标准化后的相值)之间有何不同。选取400例妇科腔镜病人,在麻醉诱导前5分钟随机接受如下药物的静脉注射:1.生理盐水;2.枢复宁4mg3,氟哌利多1.25mg4,枢复宁4mg和氟哌利多1.25mg的混合液。这些患者术中所用麻醉药物方法和术后镇痛均一致。患者术前48h内和静脉注射药物后5分钟接受心电图QT间期的检查。在含有160名患者的一组中,术后2-3h重复测量QT间期。在术后2天内,对照组术后恶心呕吐发生率高达68%,(95%CI 58-77),而单独使用枢复宁和氟哌利多能减少术后恶心呕吐发生率至30%95%CI 21-40)和28%95%CI 20-38)。混合制剂的实际效果12.1%(95%CI 6.4-20.2)和预期值11.8%(95% CI 7.1-11.9)相似(P=0.94),相似性分别为87.9%88.2%。静脉注射枢复宁,氟哌利多或混合制剂后,患者的QT间期有轻微的一过性的延长。这种变化在实验组之间相近。结论:枢复宁和氟哌利多的作用具有可性的,两种药物的药理机制各不相同,混合使用并不增QT间期延长的发生率。

(李惟一 陈杰 校)

Prophylactic ondansetron or droperidol reduces the incidence of postoperative nausea and vomiting (PONV). Previous studies showed that the combination of these two drugs produced better antiemetic effect than either drug alone. We present a nonparametric method to determine the pharmacologic interaction between ondansetron and droperidol and compared the observed response of the drug combination with that predicted from additivity. This is calculated as the product of the individual drug response, normalized to that of the controls. Five minutes before induction of anesthesia, 400 patients scheduled for laparoscopic gynecologic surgery were randomly assigned to receive 1) saline IV; 2) ondansetron 4 mg IV; 3) droperidol 1.25 mg IV; or 4) a combination of droperiodol 1.25 mg and ondansetron 4 mg IV. A standardized anesthetic technique and postoperative analgesic regimen were used. Patients were reviewed regularly for 48 h. Changes in the heart rate adjusted QT (QTc) interval were measured from electrocardiograms recorded before and 5 min after study drug administration. In a subgroup of 160 patients, QTc intervals were measured again at 2–3 h after surgery. During the first 48 h after the surgery, the proportion of patients experiencing PONV was 68% (95% CI 58–77) in the control group. A single dose of ondansetron or droperidol decreased the incidence of PONV to 30% (95% CI 21–40) and 28% (95% CI 20–38), respectively. The predicted incidence of PONV after drug combination, 11.8% (7.1–11.9), was similar to that observed, 12.1% (6.4–20.2), P = 0.94. The corresponding predicted and observed treatment responses in the combination group were 88.2% and 87.9%, respectively. There was a modest and transient increase in QTc interval after administration of ondansetron, droperidol, or their combination. The changes were however similar among groups. We conclude that the interaction between ondansetron and droperiodol was additive. Both drugs acted independently of each other through their specific mechanisms of action. The incidence of QTc prolongation did not increase with the drug combination.

 

MAC多巴胺受体是否部分介导了?

Do Dopamine Receptors Mediate Part of MAC?

Yasumasa Tanifuji, MD*, Yi Zhang, MD{dagger}, Mark Liao, BS{ddagger}, Edmond I. Eger, II, MD{ddagger}, Michael J. Laster, DVM{ddagger}, and James M. Sonner, MD{ddagger}

From the {ddagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA; *Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan; and {dagger}Department of Anesthesiology, Fuwai Hospital and Cardiovascular Institute, Beijing, People’s Republic of China.

Anesth Analg 2006 103: 1177-1181.

 

背景:中枢神经系统儿茶酚胺耗竭,包括多巴胺的缺失,可降低MAC;中枢神经系统儿茶酚胺放,包括多巴胺的放,能增MAC;纹体中游离多巴胺浓度的升高能减少MAC。这些发现提示多巴胺受体可部分介导吸入麻醉药的效能以提供对伤害刺激的制作用。方法:作者研究了多巴胺D2受体的阻滞剂氟哌利多0.3 mg/kg or 3.0 mg/kg对鼠吸入环丙烷、地氟烷、氟烷、异氟烷或七氟醚的MAC的影响,以氟哌利多(3.0 mg/kg)对依托咪酯(一种主要通过增强γ-氨基丁酸受体对γ-氨基丁酸的反应而起作用的一种麻醉药)对制伤害刺激的体反应效应需要的浓度或剂量的影响。结果:多巴胺D2受体阻滞剂氟哌利多(剂量为0.3 mg/kg 3.0 mg/kg)对鼠吸入环丙烷、地氟烷、氟烷、异氟烷或七氟醚或等剂量的依托咪酯的MAC并没有减少作用。结论:述结果其他关于多巴胺D1受体研究的数据显示多巴胺受体并不介导由吸入麻醉药产生的制作用。

(丁震敏 陈杰 校)

BACKGROUND: Depletion of central nervous system catecholamines, including dopamine, can decrease MAC (the minimum alveolar concentration of an inhaled anesthetic required to suppress movement in response to a noxious stimulus in 50% of test subjects); release of central nervous system catecholamines, including dopamine, can increase MAC; and increased free dopamine concentrations in the striatum can decrease MAC. Such findings suggest that dopamine receptors might mediate part of the capacity of inhaled anesthetics to provide immobility in the face of noxious stimulation.

METHODS: We measured the effect of blockade of D2 dopamine-mediated transmission with 0.3 mg/kg or 3.0 mg/kg droperidol on the MAC of cyclopropane, desflurane, halothane, isoflurane, or sevoflurane in rats, and the effect of 3.0 mg/kg droperidol on the dose or concentration of etomidate (an anesthetic known to act principally by enhancing the response of {gamma}-aminobutyric acidA receptors to {gamma}-aminobutyric acid) required to suppress movement in response to noxious stimulation.

RESULTS: Blockade of D2 dopamine-mediated transmission with droperidol does not decrease the MAC of cyclopropane, desflurane, halothane, isoflurane, or sevoflurane or its equivalent for etomidate in rats.

CONCLUSIONS: These data, plus data from studies by others about D1 dopamine receptors, indicate that dopamine receptors do not mediate the immobility produced by inhaled anesthetics.

 

围术期监测仪数据不实的问题:一篇临方法的综述

The Problem of Artifacts in Patient Monitor Data During Surgery: A Clinical and Methodological Review

George Takla, MS, John H. Petre, PhD, D. John Doyle, MD, PhD, Mayumi Horibe, MD, and Bala Gopakumaran, PhD

From the Division of Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio.

Anesth Analg 2006 103: 1196-1204.

 

监测仪数据不实影响在手术中正确获取监测信息的问题已经引起了广泛的关注,这亦是引起虚假警的原因之一。第二个问题是自保存系统会记录下错误的监测信息。尽管目前大部分的监测仪已采取了许多措施来减少监测仪数据不实的发生,但是,他们的作用是有限的。作者回顾了在手术期间病人监测仪数据不实的病例,讨论了目前市的病人监测仪采用的消除和最小化不实数据的措施包括术方面和环境因子等,也探讨了正在研究中的检测和校正方法。这些将会用于检测和消除监测仪数据不实,提高监测仪的准确性和特异性。

(杨卫红 陈杰 校)

Artifacts are a significant problem affecting the accurate display of information during surgery. They are also a source of false alarms. A secondary problem is the inadvertent recording of artifactual and inaccurate information in automated record keeping systems. Though most of the currently available patient monitors use techniques to minimize the effect of artifacts, their success is limited. We reviewed the problem of artifacts affecting patient monitor data during surgical cases. Methods adopted by currently marketed patient monitors to eliminate and minimize artifacts due to technical and environmental factors are reviewed and discussed. Also discussed are promising artifact detection and correction methods that are being investigated. These might be used to detect and eliminate artifacts with improved accuracy and specificity.

 

右旋美托咪啶用于震颤性麻痹病人深部脑刺激物植入术的临经验

Clinical Experience with Dexmedetomidine for Implantation of Deep Brain Stimulators in Parkinson's Disease

Irene Rozet, MD*, Saipin Muangman, MD*, Monica S. Vavilala, MD*{dagger}, Lorri A. Lee, MD*, Michael J. Souter, MB, ChB, FRCA*, Karen J. Domino, MD*, Jefferson C. Slimp, PhD{ddagger}, Robert Goodkin, MD, and Arthur M. Lam, MD, FRCPC*

From the Departments of *Anesthesiology, {dagger}Pediatrics, {ddagger}Rehabilitation Medicine, and Neurological Surgery, University of Washington, Seattle, Washington.

Anesth Analg 2006 103: 1224-1228.

{alpha}-2受体激剂右旋美托咪啶(Dex)的药理学特性表明它有可能是一种理想的镇静药物用于深部脑刺激物植入术。作者将2001年到2004年实施深部脑刺激物植入术的病人的麻醉记录进行了一项回顾性的分析。2003年开始,应用Dex作为镇静药用于深部脑刺激物植入术。比较两组病人间人口统计学资料、高血压药物的使用连续脑电图,一组病人给予Dex (11 名患者/13 次操作) ,另一组病人不给予任何的镇静药 (对照组: 8名患者/9次操作)。两组病人的疾病严重程度没有差异。Dex使病人舒适外科满意,并显著降低了高血压药物的使用(Dex组为54%, 对照组为100%, P = 0.048)。深部脑刺激物植入术中,用Dex 镇静没有干扰脑电图, 能使血液学稳定病人舒适。因此。这些手术中应常规使用Dex

(宋金超 陈杰 校)

The pharmacologic profile of the {alpha}-2 agonist dexmedetomidine (Dex) suggests that it may be an ideal sedative drug for deep brain stimulator (DBS) implantation. We performed a retrospective chart review of anesthesia records of patients who underwent DBS implantation from 2001 to 2004. In 2003, a clinical protocol with Dex sedation for DBS implantation was initiated. Demographic data, use of antihypertensive medication, and duration of mapping were compared between patients who received Dex (11 patients/13 procedures) and patients who did not receive any sedation (controls: 8 patients/9 procedures). There were no differences in severity of illness between the two groups. Dex provided patient comfort and surgical satisfaction with mapping in all cases, and significantly reduced the use of antihypertensive medication (54% in the Dex group, versus 100% in controls, P = 0.048). In DBS implantation, sedation with Dex did not interfere with electrophysiologic mapping, and provided hemodynamic stability and patient comfort. Routine use of Dex in these procedures may be indicated.

 

先兆子痫病人行麻对QT间期的影响

The Effects of Spinal Anesthesia on QT Interval in Preeclamptic Patients

Selda Sen, MD*, Galip Ozmert, MD{dagger}, Hakan Turan, MD{dagger}, Eray Caliskan, MD{dagger}, Alper Onbasili, MD{ddagger}, and Duran Kaya, MD

From the Departments of *Anaesthesiology and {ddagger}Cardiology, Adnan Menderes University, Aydin, Turkey; {dagger}Department of Obstetric and Gynecology, SSK Ankara Maternity and Women's Health Teaching Hospital; and Department of Internal Medicine, Ankara University, Ankara, Turkey.

Anesth Analg 2006 103: 1250-1255.

 

本文作者研究麻对严重先兆子痫的孕妇QT间期的影响。25位先兆子痫的病人(先兆子痫组)和25位有着正常脉血压和QT间期的健康的娠妇女(对照组)进行前瞻性、病例对照研究。麻醉前,以麻起效之后的510203060,和120分钟分别记录脉压,心率和QT间期(基线值)。同时记录麻黄素使用总量,感觉阻滞所需时间,以Apgar评分。麻前,先兆子痫组的QT间期(452 ±17.5)明显长于对照组(376 ±21.4)。然而在先兆子闲组中,麻后QT间期缩短,而对照组没有显著变化。结论:QT间期在有高血压和低血钙的重度先兆子闲病人可能延长。麻能使QT间期延长的剖腹产产妇QT间期正常,可能由于交感阻滞所致。

(郑丽 陈杰 校)

In this study, we measured the effects of spinal anesthesia on the corrected QT (QTc) interval in women with severe preeclampsia. Twenty-five preeclamptic (preeclamptic group) and 25 healthy pregnant women with normal arterial blood pressure and QTc interval (control group) were enrolled in this prospective, case-controlled study. Arterial blood pressure, heart rate, and QTc interval values were obtained before (baseline value) and at 5, 10, 20, 30, 60, and 120 min after initiation of spinal anesthesia. Total ephedrine dose, time elapsed until sensory block, and Apgar scores were recorded. Prior to spinal anesthesia, QTc interval values were significantly higher in the preeclamptic group (452 ± 17.5 ms) when compared with that in controls (376 ± 21.4 ms). Although the QTc interval shortened during spinal anesthesia when compared with baseline value in the preeclamptic group (P < 0.05), it showed no significant change in the control group. In conclusion, the QTc interval may be prolonged in severe preeclamptic patients who have hypertension and hypocalcemia. Spinal anesthesia for cesarean delivery may normalize that prolonged QTc interval due to sympathetic blockade.


塞来昔布(Celecoxib),普瑞巴林(Pregabalin)其联合使用在柱融合手术中的镇痛效果

The Analgesic Efficacy of Celecoxib, Pregabalin, and Their Combination for Spinal Fusion Surgery

Scott S. Reuben, MD*, Asokumar Buvanendran, MD{dagger}, Jeffrey S. Kroin, PhD{dagger}, and Karthik Raghunathan, MD*

From the *Department of Anesthesiology, Baystate Medical Center, Springfield, Massachusetts; and {dagger}Department of Anesthesiology, Rush Medical College, Chicago, Illinois.

Anesth Analg 2006 103: 1271-1277.

 

背景:最佳的术后镇痛效果很难通过使用单一药物来实现。因此,许多专家建议应用两种或两种以的药物合用以降低药物的副作用。在这个试验中,作者评估了围手术期使用塞来昔布,普瑞巴林或两者合用时在柱融合手术术后镇痛效果。方法80位患有柱融合后择期行腰椎间盘减压手术的病人随机口服给药:术前1h和术后12h分别给予安慰剂;术前1h给予塞来昔布400mg术后12h给予塞来昔布200mg;术前1h和术后12h分别给予普瑞巴林150mg;或术前1h给予合剂(塞来昔布/普瑞巴林400mg/150mg)和术后12h给予合剂(塞来昔布/普瑞巴林200mg/150mg)。结果:塞来昔布/普瑞巴林组病人自控镇痛的吗啡消耗量最少。单独给予塞来昔布或普瑞巴林组的阿片用量较安慰剂组也有减少,但是不如联合使用减少的多。在围手术期的24h中,无论是病人休息还是活态下,联合使用塞来昔布和普瑞巴林是最有效的缓解疼痛的方法。但是四组的血流学和呼吸频率没有显著差异。联合用药组呕吐的发生率低于安慰剂组。

结论:相对于柱融合术后单独使用塞来昔布或普瑞巴林,围手术期联合使用塞来昔布和普瑞巴林能改善镇痛效果且副作用小。

(周密 陈杰 校)

BACKGROUND: As optimal pain relief after surgery is difficult to achieve with the use of just one drug, many pain experts advocate the use of two or more classes of medications so as to reduce the side effects from any one drug. In this trial, we assessed the analgesic efficacy of administering perioperative celecoxib, pregabalin, or both after spinal fusion surgery.

METHODS: Eighty patients scheduled to undergo elective decompressive lumbar laminectomy with posterior spinal fusion were randomized to receive oral medications: placebo 1 h before and 12 h after surgery, celecoxib 400 mg 1 h before and celecoxib 200 mg 12 h after surgery, pregabalin 150 mg 1 h before and 12 h after surgery, or a pregabalin/celecoxib combination of 400 mg/150 mg 1 h before and 200 mg/150 mg 12 h after surgery.

RESULTS: The pregabalin/celecoxib group consumed the least patient-controlled morphine. Celecoxib alone or pregabalin alone also reduced opioid use compared with placebo, but not as much as when combined. The pregabalin/celecoxib combination was the most effective treatment for reducing pain both at rest and with movement over the 24-h postoperative time period. Hemodynamics and respiratory rate did not differ among the four treatment groups. Fewer patients experienced nausea in the pregabalin/celecoxib group compared with that in the placebo group.

CONCLUSION: The perioperative administration of the combination of celecoxib and pregabalin improved analgesia and caused fewer side effects, than either analgesic drug alone after spinal fusion surgery.

 

妇科手术后的疼痛模式:鞘内注射和全身使用吗啡的不同效应

A Pain Model After Gynecologic Surgery: The Effect of Intrathecal and Systemic Morphine

Chuanyao Tong, MD, Dawn Conklin, BA, and James C. Eisenach, MD

From the Department of Anesthesiology, Pain Mechanisms Laboratory, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Anesth Analg 2006 103: 1288-1293.

背景:尽管最近的研究证实内脏痛和躯体痛在神经病理基础和治疗均不同,但是对术后疼痛的大多数实验研究都采用躯体表面痛的模型,而且没有产科手术后疼痛的模型。作者描述了大鼠剖腹术后有或无子宫和宫颈的不良刺激的自发行为,以求得对产科术后疼痛的专项描绘。方法:雌SD大鼠采用分别只吸入麻醉,仅在麻醉后剖腹术或剖腹术后对低位子宫和宫颈进行60 min的紧张性扩张,然后观察其行为。结果:与仅吸入麻醉的大鼠比较剖腹术的大鼠的自发性活(饮水,整理,探察)减少。剖腹术宫颈的操作进一步减少了这些活,增了异常活(甜下腹部和骨盆位置压在地面)。鞘内注射和全身用吗啡可以恢复自发活和减少异常活,两种不同的用药方式有微小的不同。结论:这些数据表明一些特的行为直接反映了产科术后疼痛躯体和内脏痛的组成,同时这个模型可用于检验减轻疼痛的新的治疗方案。

(王震虹 陈杰 校)

BACKGROUND: Despite recent recognition that visceral pain differs from somatic pain in its neurophysiologic basis and treatment modalities, most laboratory studies of postoperative pain use a model of superficial somatic injury, and there is no model of postoperative pain after gynecologic surgery. We describe spontaneous behavior in rats after laparotomy with or without noxious stimulation of the uterus and cervix to more specially address pain after gynecologic surgery.

METHODS: Female Sprague-Dawley rats received inhaled anesthesia only, anesthesia with laparotomy, or laparotomy plus 60 min of tonic distension of the lower uterine segment and cervix, followed by video observation of spontaneous behavior.

RESULTS: Compared with anesthesia alone, laparotomy decreased some spontaneous behaviors (drinking water, grooming, and exploration). Laparotomy plus uterocervical manipulation further decreased these behaviors and increased abnormal behaviors (licking of the lower abdomen and squashing posture of the pelvis to the floor). Intrathecal and systemic morphine restored spontaneous behavior and reduced abnormal behaviors, with minor differences between routes of administration.

CONCLUSIONS: These data suggest that specific behaviors may distinctly reflect somatic and visceral components of postoperative gynecologic pain, and that this model may be used to test novel therapies to relieve pain in this setting.

 

胫后神经阻滞中一个近端阻滞点的评估和神经刺激导向装置针的使用

Evaluation of a Proximal Block Site and the Use of Nerve-Stimulator-Guided Needle Placement for Posterior Tibial Nerve Block

Robert Doty, Jr, MD, Radha Sukhani, MD, Mark C. Kendall, MD, Edward Yaghmour, MD, Antoun Nader, MD, Alina Brodskaia, MD, Tripti C. Kataria, MD, and Robert McCarthy, DPharm

From the Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.

Anesth Analg 2006 103: 1300-1305

.

背景:在没有神经刺激器(NS)引导的情况下,胫后神经(PTN)阻滞传统是在旁正中踝区域完成的。PTN还可以在拇长屈肌腱和趾长屈肌腱之间的筋膜下平面内踝向大约7cm处阻滞。在这项研究中,作者比较了使用和不使用NS向导的情况下,在传统的远中心端(D)(内踝2cm)成实施PTN阻滞的频率。还比较了D位点和近中心位点(P)的阻滞的成率和潜伏时间。方法:受试者随机分到P-NS(n=45)D-NS(n=45)D不使用NS(n=45)。所有阻滞都使用0.625%左布比卡因0.15mL/kg。在足底内侧神经,足底外侧神经和跟骨内侧神经的分布区域评价针刺感觉的麻痹。如果PTN的所有分布区域都达到了手术麻醉效果则认为PTN阻滞成。结果:D组(73.3%)相比,D-NS(100%)P-NS(93.5%)PTN阻滞成率更高(P=0.02)D-NS组达到阻滞的平均潜伏时间(8min95% CI 7-9min)D(20min95% CI 13-26min)(P<0.01)P-NS(15min95% CI 12-18min)(P=0.04)短。结论NS导向装置针提高了D位点阻滞成率并减少了D位点达到PTN阻滞的潜伏时间。用P位点来阻滞PTN可能是另一个有效的选择,特别是对那些无法接近D位点的病人。

(顾新宇 陈杰 校)

BACKGROUND: Posterior tibial nerve (PTN) block has traditionally been performed in the para-medial malleolar area without nerve stimulator (NS) guidance. The PTN can also be blocked proximally (7 cm) above the medial malleolus in the subfascial plane between the flexor hallucis longus and flexor digitorum longus tendons. In this study we compared the frequency of successful PTN block at the traditional distal (D) site (2 cm above the medial malleolus) with and without NS guidance. We also compared block success and latency at the D site versus the proximal (P) block site.

METHODS: Subjects were randomized to P-NS (n = 45), D-NS (n = 45), or D without NS (n = 45). Levobupivacaine 0.625%, 0.15 mL/kg was used for all blocks. Pinprick sensory anesthesia was evaluated in the distribution of the medial plantar, lateral plantar, and medial calcaneal nerves. PTN block was considered successful if surgical anesthesia was achieved in all PTN distributions.

RESULTS: The frequency of successful PTN block was greater for D-NS (100%) and P-NS (93.5%), compared with D (73.3%) (P = 0.02). Median latency to complete block was less for D-NS (8 min, 95% CI 7-9 min) than D (20 min, 95% CI 13-26 min) (P < 0.01) and P-NS (15 min, 95% CI 12-18 min) (P = 0.04).

CONCLUSIONS: NS-guided needle placement improves the success and decreases the latency to onset of complete PTN block at the D site. The P approach to PTN block may be a useful alternative to the traditional D site approach, particularly in patients with restricted access to the D site.

 

比较中胸段和低胸段硬膜外间隙硬膜外压和低于大气压的硬膜外压的发生率的差异

A Comparison of Epidural Pressures and Incidence of True Subatmospheric Epidural Pressure Between the Mid-Thoracic and Low-Thoracic Epidural Space

W. Anton Visser, MD*, Mathieu J. M. Gielen, MD, PhD{dagger}, Janneke L. P. Giele, MSc{dagger}, and Gert J. Scheffer, MD, PhD{dagger}

From the *Department of Anesthesiology, Intensive Care and Pain Management, Amphia Hospital, 4800 RL Breda, The Netherlands; and {dagger}Department of Anesthesiology, University Medical Center Nijmegen, 6500 HB Nijmegen, The Netherlands.

Anesth Analg 2006 103: 1318-1321.

背景:硬膜外压的差异可能会影响胸段硬膜外阻滞麻药的扩散。作者评估了中胸段和下胸段硬膜外间隙压是否存在差异以低于大气压的硬膜外压发生率的差异。方法:两组分别在胸3-5(中胸段组,n=20)和胸7-10(低胸段组,n=20)椎间隙放置了硬膜外导管。确认硬膜外腔的方法是使用连接传感器的针,从而测得硬膜外压。结果:有三位病人无法确定硬膜外腔从而从研究中剔出。硬膜外压数据以中位数(中四分位范围)表述。中胸段组中位硬膜外压是1mmHg-14.5),低胸段是4mmHg2-7.8)(P=0.04)。硬膜外压低于0mmHg的发生率中胸段组是8/17,低胸段组是2/20。(P=0.02)。结论:中胸段硬膜外腔的压低于低胸段组,而低于大气压的硬膜外压的发生率高于低胸段组。但是,硬膜外压的中位数两组都是正值。这种压梯度是否会影响胸段硬膜外阻滞的扩散仍需要经一步的研究。

(曹瑜 陈杰 校)

BACKGROUND: Differences in epidural pressure (EP) may influence the spread of blockade in thoracic epidural anesthesia. We evaluated if EP and the incidence of subatmospheric EP differ between the mid- and low-thoracic epidural space.

METHODS: Patients received an epidural catheter at the T3-5 (MID group, n = 20) or T7-10 (LOW group, n = 20) intervertebral space, respectively. The epidural space was identified using a Tuohy needle connected to a pressure transducer, after which EP was measured.

RESULTS: The epidural space could not be identified in three patients who were excluded from the study. EP data are presented as median value (interquartile range). Median EP was 1 mm Hg (–1 to 4.5) in the MID group, and 4 mm Hg (2-7.8) in the LOW group (P = 0.04). The incidence of an EP 0 mm Hg was 8 of 17 patients in the MID group and 2 of 20 patients in the LOW group (P = 0.02).

CONCLUSIONS: We conclude that EP is lower, and the incidence of subatmospheric EP is higher in the mid-thoracic epidural space when compared with that in the low-thoracic epidural space. However, median EP was positive in both groups. It remains to be investigated whether this pressure gradient is sufficient to influence the spread of thoracic epidural blockade.